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From YouTube: 4/5/2021 - Assembly Committee on Commerce and Labor, 6pm
Description
For agenda and additional meeting information: https://www.leg.state.nv.us/App/Calendar/A/
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A
Here,
thank
you
so
much.
Madam
secretary,
please
indicate
that
all
committee
members
are
present
welcome
to
our
audience
tuning
in
over
the
internet.
Before
we
start,
I
would
like
to
make
some
housekeeping
announcements.
Please
remember
all
exhibits,
written
testimony
and
amendments
must
be
submitted
by
noon.
On
the
business
day
prior
to
the
committee
meeting
persons
wishing
to
provide
testimony
or
attend
the
meeting
virtually
must
pre-register
online
at
the
legislature's
website.
A
The
public
is
strongly
encouraged
to
submit
written
testimony
in
advance
of
the
meeting
by
emailing
the
assembly
committee
on
commerce
and
labor
members.
Please
remember
to
keep
your
cameras
on
at
all
times.
This
will
help
us
ensure
that
we
have
a
quorum
unless
you're
stepping
away
for
non-committee
related
business
members
and
presenters.
Please
remember
to
be
muted
at
all
times,
unmute
yourself
to
speak
and
then
promptly
mute
yourself
when
you
are
done.
Thank
you
to
everyone
who
has
joined
us
today
and
let's
get
started
with
our
agenda.
A
We
have
one
agenda
item
one
bill
on
the
agenda
item
for
today's
hearing
and
it
is
assembly
bill
387.
With
that,
I
will
open
the
hearing
on
assembly
bill
387,
which
revises
provisions
relating
to
midwives.
I
have
assembly
member
danielle
monroe
moreno
with
us
to
present
when
you're
ready
assembly
member
the
floor
is
yours.
D
D
D
A
midwife
monitors,
the
physical,
psychological
and
social
well-being
of
birthing
parent
through
the
childbearing
cycle,
when
needed,
a
midwife
identifies
and
refers.
The
few
women
who
need
ob
attention,
midwives,
who
attend
births
at
home
and
in
birth
centers,
have
excellent
outcomes
and
costs
approximately
one-third
less
than
hospital
deliveries,
the
latter
of
which
account
for
approximately
110
billion
a
year
in
health
care
cost,
which
is
just
in
the
united
states.
D
D
D
D
D
So
that's
the
premise
for
ab387
licensure
is
a
key
to
providing
safe
care
for
nevadans.
That
is
consistent
with
the
scope
of
practice
defined
by
the
profession.
It
also
makes
midwifery
more
accessible
and
enables
them
to
participate
in
an
integrated
system
that
includes
opportunities
for
consultation,
collaboration,
referral
and
multi-disciplinary
peer
review.
D
Miss
hoffman
and
ms
mcdonald
have
been
working
with
me
for
over
a
year
now
to
bring
this
bill
to
this
legislative
body.
We
have
been
involved
with
stakeholder
meetings,
numerous
stakeholder
meetings
up
until
saturday
night,
when
I
think
we
had
almost
a
four-hour
meeting
and
receiving
amendments
to
this
bill
up
until
2
30.
Today
we
have
done
our
due
diligence.
It's
not
a
perfect
bill.
I
don't
know
if
there
ever
is
one,
but
we
are
trying
to
get
to
perfection.
A
B
Hello,
thank
you,
madam
chair
and
assemblywoman
monroe,
moreno
and
the
rest
of
the
committee
for
this
opportunity
to
speak
and
thank
you
for
the
baby
cheeks
at
the
beginning
of
this.
To
make
us
feel
right
at
home.
B
My
name
is
tiffany
hoffman
and
I'm
here
with
my
colleague
amanda
mcdonald,
and
we're
certified
professional
midwives
practicing
in
rita
in
reno,
as
well
as
licensed
midwives
in
the
state
of
california.
We
want
to
talk
to
you
today
about
our
interest
in
the
licensure
for
certified
professional
midwives
in
the
state
of
nevada.
B
B
We
have
reviewed
research
statements
from
major
organizations
invested
in
the
safety
of
community
birth,
listened
to
consumers
of
all
types
of
midwifery
services,
families
that
have
experienced
losses
and
bad
outcomes,
every
type
of
midwife,
the
hospital
association,
physicians,
lobbyists
and
legislators
in
creating
this
bill.
Everyone
interested
in
this
topic
is
extremely
passionate
and
there
is
little
middle
ground.
B
Every
attempt
has
been
made
to
come
to
a
center
the
questions
we
asked
in
creating
this
bill
over
the
last
year,
where
how
can
we
improve
safety
and
satisfaction
for
consumers?
How
do
we
honor
and
respect
the
history
of
midwifery
while
advancing
the
profession?
How
do
we
protect
choice
for
nevada
families?
B
B
B
Okay,
so
what
is
a
certified
professional
midwife?
A
cpm
is
an
autonomous
primary
perinatal
care
provider
for
pregnant
people
with
healthy
pregnancies.
We
are
distinctly
different
from
the
profession
of
nursing
or
medicine.
We
provide
comprehensive
care
prenatally
during
labor
and
birth
during
the
and
during
the
postpartum
period.
We
also
provide
well
woman
well-person
care
in
the
perinatal
period,
including
pap
smears
and
sti
testing.
We
are
experts
in
the
wellness-centered
model
of
care
and
the
physiologic
approach
to
pregnancy
and
birth,
our
expertise
in
providing
care
in
the
in
home
and
freestanding
birth
centers.
B
So
what
are
the
benefits
of
cpm
care,
because
we
are
able
to
offer
a
truly
personalized,
one-on-one,
physiologic
approach
to
perinatal
care
for
healthy
pregnancies?
We
see
a
significant
reduction
in
intervention
during
labor
and
birth.
For
example,
we
see
a
substantially,
we
see
substantially
lower
rates
of
inductions
in
cesarean
compared
with
the
medical
model
of
care,
and
we
provide
ourselves
on
providing
client-centered
care
and
high
and
highly
value
shared
decision.
Making.
B
Midwifery
care
and
access
to
midwives
in
all
settings
were
associated
with
significant
increases
in
spontaneous
vaginal
births,
successful
vaginal
births
after
cesarean
breastfeeding
at
six
months,
and
a
significant
reduction
in
c-section
rates,
pre-term
birth
and
low
birth
weight.
We
will
speak
further
to
this
later
in
the
presentation.
B
Benefits
of
cpm
care
in
the
state
of
nevada
also
include
medicaid
cost
savings
due
to
lower
intervention,
invention,
lower
intervention
rates
and
cesarean
rates.
This
map
shows
the
current
licensing
trends
in
the
united
states.
36
states
offer
licensure
to
cpms
and,
as
you
can
see,
nevada
stands
alone
in
the
west
as
the
only
unlicensed
state.
B
According
to
the
mapping
integration
of
midwives
across
the
united
states,
study,
which
was
published
in
2018
outcomes,
are
best
globally
when
midwives
are
regulated
and
practiced
to
their
full
scope.
This
study
convened
a
multi-disciplinary
task
force
with
expertise
in
maternity
services,
research,
public
health,
midwifery,
obstetrics,
epidemiology,
consumer
advocacy
and
and
or
roles
in
midwifery
legislation,
regulation
and
law
in
2014.
B
These
are
midwifery
integration
scores
and
the
midwifery
integration
scoring
system
was
created
by
a
multi-disciplinary
group
of
experts
to
determine
whether
integration
of
midwives
into
the
health
care
system,
improved
outcomes,
a
missed
score
of
a
hundred
would
indicate
that
a
family
in
that
state
would
have
full
access
to
high
quality
maternity
care
in
all
settings.
Higher
missed
scores
were
associated
with
significantly
more
access
to
midwives,
significantly
higher
rates
of
physiologic
birth
outcomes,
lower
rates
of
obstetric
interventions
and
fewer
adverse
neonatal
outcomes.
B
B
B
B
50
to
75
percent
of
births
are
attended
by
midwives
in
other
high
resource
countries.
On
this
slide,
we
see
that
the
states
with
higher
miss
scores
all
have
significantly
higher
rates
of
midwifery
care
than
nevada's
mere
five
percent,
and
all
three
were
also
higher
than
the
national
and
all
three
were
also
higher
than
the
national
average.
B
We
see
a
significant
increase
in
spontaneous
vaginal
births
vaginal
births
after
caesareans
and
breastfeeding,
both
at
birth
and
six
months.
You
can
also
see
a
huge
difference
in
cesarean
rates,
nationally,
higher
missed
scores
are
correlated
with
lower
rates
of
pre,
premature
birth,
low
birth
weight
and
neonatal
mortality.
B
Why
did
they
look
at
birth
settings?
They
looked.
They
started
this
report
because
the
us
has
the
highest
mortality
and
morbidity
rates
among
all
high
resource
countries,
despite
spending
the
most
care
that
is
evidence-based,
linguistically
and
culturally,
appropriate
and
safe
is
not
available
to
everyone.
This
is
all
despite
the
fact
that
the
majority
of
u.s
pregnancies
are
low
risk.
B
Additionally,
black
birthing
people
and
babies
die
at
rates
much
higher
than
their
white
counterparts.
They
are
two
to
six
times
more
likely
to
die
in
childbirth,
depending
on
where
in
the
country
they
are
giving
birth
conclusions
that
the
birth
setting
report
the
birth
settings
report
came
to
is
that
the
u.s
maternity
care
system
under
underutilizes,
evidence-based
beneficial
care
and
overuses
care.
That
is
not
medically
indicated.
In
other
words,
it
is
either
too
much
too
soon
or
too
little
too
late,
and
we
are
striving
for
the
right
amount
of
care
at
the
right
time.
B
Not
yet
sorry
we're
going
to
go
back,
one
slide
so
to
improve
outcomes
generally
and
we're
going
to
flip
back
through
provide
so
to
improve
outcomes
generally.
What
was
advised
is
to
provide
respectful,
high
quality
care,
provide
true
informed
consent
and
informed
refusal
around
decision
making
regarding
risk
in
all
maternity
care
settings
integrated
in
collaborative
care
between
all
birth,
sending
earth
settings,
increase,
access
to
affordable,
safe,
respectful,
linguistically
and
culturally
appropriate
prenatal
and
mental
health
care
that
works
to
reduce
disparities
created
by
structural
racism
and
the
long-term
effects.
B
The
suggestions
for
improving
hospital
birth,
we're
developing
midwifery-led
units
in
the
hospital
setting
greater
collaboration
between
maternity
care
providers,
teaching
and
providing
respectful
care
and
true
informed
consent
and
refusal,
and
decreasing
unnecessary
intervention
for
the
home
and
birth
center,
setting
the
things
that
that
were
recommended
to
be
improved,
we're
integrating
home
and
birth
centers
into
a
regulated,
maternal
newborn
care
system,
shared
care
and
access
to
safe
and
timely
transport.
Seamless
transfer
across
settings
appropriate
and
ongoing
client
risk
assessment
and
risk
selection.
B
Well.
Qualified
maternity
care
providers
with
training
to
manage
first-line
complications,
access
to
licensure
at
the
state
level,
and
mechanisms
for
obtaining
and
maintaining
accreditation
for
birth
centers
to
improve
access
and
quality
of
care
and
the
ability
of
all
cnms
cms
cpms
who
meet
icm
standards
to
practice
to
the
full
extent
of
their
scope.
B
B
Ab387
would
require
a
meek,
accredited
education
after
january
1st
2025,
with
the
opportunity
to
apply
for
an
extension
to
this
date
for
rural
students
and
students
from
groups
with
marginalized
identities,
which
are
defined
as
an
identity
that
causes
or
has
historically
caused
a
person
of
such
an
identity
to
be
disproportionately
subjected
to
discrimination,
harassment
or
other
negative
treatment.
As
a
result
of
that
identity,
ab387
would
require
direct
on-site
supervision
of
students
and
midwife
assistants
by
certified
professional
midwives.
B
B
U.S
mayor
includes
the
national
association
of
certified
professional
midwives,
the
association
of
certified
nurse
midwives
and
their
certifying
agency
amcb,
the
national
association
to
advance
black
birth
and
the
north
american
registry
of
midwives.
U.S
mara's
vision
was
to
come
up
with
ways
to
help
build
an
integrative
health
care
system
where
everyone
has
access
to
midwives
and
midwifery
care
that
improves
health.
One
of
the
ways
they
recommended
to
to
work
towards
the
goal
was
to
encourage
states
presenting
new
licensure
bills
for
cpms
to
require
meek,
accredited
education
for
midwives
certifying
after
january,
1st
2020.
B
eleven
of
the
last
12
jurisdictions
to
pass
cpm
licensure
laws.
Since
events
have
included
this
u.s
mara
language
requiring
an
accredited
accredited
education
in
their
licensing
bills.
All
the
other
states
currently
working
to
pass
licensure
laws
are
including
u.s,
marriage,
u.s
mara
language
as
well
an
overview.
B
Where
an
overview
of
the
current
routes
of
oh
wait,
what
are,
what
is
a
meek,
accredited
program
and
its
benefits?
B
B
Meek
is
approved
to
accredit
midwifery
programs
by
the
u.s
secretary
of
education.
The
education
requirements
required
by
meek
for
cpms
meet
international
confederation
of
midwives,
minimum
educational
standards
without
any
additional
ceus.
This
route
honors
the
legacy
of
learning
through
the
centuries-old
apprenticeship
model,
while
adding
a
standardized,
evidence-based
didactic
component
that
will
foster
well-rounded
community
community
midwifery
providers.
B
This
route
requires
the
completion
of
a
three-year
accredited
education
program,
as
well
as
a
minimum
two-year
apprenticeship
with
with
a
narm
and
school-approved
preceptor.
Candidates
may
then
sit
for
their
credentialing
exam
meet
accreditation
verifies
that
a
program
meets
established
standards
of
education.
It
provides
an
opportunity
for,
inter
and
intra-institutional
cooperative
learning
and
practices.
This
can
be
the
basis
for
a
future
collect
for
future
collaborative
relationships
with
hospital-based
providers.
B
Meek
promotes
ongoing
improvement
of
programs
and
creates
a
system
for
accountability
for
students.
Preceptors
and
staff.
It
also
helps
guide
financial
support
for
midwifery
education
nacpm,
as
well
as
six
other
organizations
in
u.s
mara
support,
mika
credited
education
as
a
requirement
for
the
newly
licensing
states
to
be
clear.
Ab-387
would
only
require
meek.
Accredited
education
for
newly
credentialing
cpms
current
cpm's
trained
to
the
process
would
only
need
to
complete
the
midwifery
bridge
program
previous
previously
mentioned
by
2025..
B
B
B
According
to
narm,
the
pep
process
originally
began
as
a
way
for
midwives
with
experience
and
skills
to
have
their
qualifications
evaluated
for
credentialing
prep
is
an
educational,
competency-based
evaluation
process
with
three
different
educational
requirements
before
sitting
for
the
the
credentialing
exam
part,
one,
a
list
of
general
education
requirements.
Reading
material
and
resources
are
provided
to
candidates
to
be
studied.
Part
two,
a
minimum
two
year,
apprenticeship
with
an
arm
approved,
preceptor
and
part
three,
a
clinical
skills
verification
which
requires
two
percep
preceptors
to
sign
off
on
skills
competency.
B
B
The
international
confederation
of
midwives
supports
the
creation
of
international
minimum
educational
standards
for
midwives.
The
midwifery
bridge
certificate
requires
15
ceus
in
emergency
skills,
15
and
emergency
newborn
skills
and
20
ceus
designated
as
other.
This
program
must
be
completed
within
five
years.
B
So
why
is
accreditation
and
licensure
good
for
the
public
and
how
is
it
going
to
benefit
nevada
families?
We
know
that
meek,
accredited
schools
are
meeting
certain
standard
criteria
for
the
curriculum.
We
know
that
the
full
gamut
of
educational
topics
are
being
required
in
a
student's
didactic
course.
This
is
important
for
the
health
and
safety
of
nevada
families,
whether
certified
or
not.
B
I
think
midwives
can
agree
that
there
is
a
difference
between
being
able
to
pass
a
certification
exam
and
truly
understanding
midwifery
topics
in
depth
required
for
safe
practice,
meek
education
helps
ensure
topics
are
not
being
overlooked
or
skimmed
over.
There
is
accountability
for
the
schools,
accountability
for
preceptors
and
accountability
for
the
students.
If
the
students
are
having
an
issue
with
the
preceptor,
they
have
a
resource
for
help.
If
a
preceptor
has
a
concern
about
a
student,
they
have
resources
to
help.
B
B
Accreditation
can
also
save
the
state
money
meek.
Accredited
schools
already
have
processes
in
place
for
monitoring
and
evaluating
students.
Education,
so
states
can
trust
that
the
schools
have
provided
appropriate
education
and
training
without
needing
to
create
their
own
state
process
to
evaluate
applicants
before
licensure
licensure
provides
a
way
to
hold
midwives
accountable
if
practicing
outside
of
their
scope
or
otherwise
practicing
unsafely.
If
there
is
a
bad
outcome,
there
are
official
processes
and
paths
to
possible
re
recourse
for
both
the
family
and
the
state,
if
warranted.
B
B
B
Why
is
accreditation
and
licensure
good
for
the
midwifery
profession,
accreditation,
promotes
standards
of
practice
and
advocates
for
rigorous
preparation?
As
I
previously
noted,
this
is
important
for
public
health
and
safety.
One
of
the
big
arguments
against
requiring
meek
accredited
education
is
that
is
that
of
access
for
students.
Meek
education
is
often
much
more
expensive
than
the
pep
process
route.
However,
an
overlooked
part
of
the
discussion
of
student
access
is
the
availability
of
funding.
Many
meek.
Accredited
schools
have
federal
funding
options
via
grants
and
loans
available.
B
Just
like
a
standard
college
program
would
mary
lawler
the
executive
director
of
nacpm
national
has
been
working
to
secure
funding
for
midwifery
education
through
the
midwives
for
maximizing
optimal
maternity
services.
Act
of
2019
that
act
secures
35
million
of
funding
through
title
7
and
8
available
for
midwifery
students
in
accredited
programs
for
expanding
midwifery
programs
and
to
help
support
more
preceptors.
There
is
2.5
million
designated
specifically
for
underrepresented
students
in
midwifery
education
to
help
support
the
development
of
a
midwifery
workforce
that
represents
the
racial
and
ethnic
demographic
of
the
childbearing
population.
B
Another
access
concern
is
having
to
leave
one's
community
to
complete
their
education.
There
are
several
meek,
accredited
schools
which
will
require
only
occasional
travel
to
campus
and
in
some
cases
none
at
all
and
students
can
remain
in
their
own
communities,
one
hundred
percent
of
the
time
working
with
a
local
preceptor.
B
B
Okay,
as
for
licensure,
it
fosters
accountability.
Peer
review
is
typically
required
for
license
renewal
midwives
can
hold
each
other
accountable,
knowing
what
the
what
the
standards
of
practice
are
supposed
to
be.
There
is
what
this
is,
where
consistency
and
knowledge
base
and
skills
also
come
into
play
through
these
peer
reviews.
Midwives
can
help
each
other
find
potential
deficits
or
oversight
in
their
practices,
and
licensure
would
open
up
the
opportunity
for
interdisciplinary
peer
reviews.
B
B
Our
ab387
would
also
specifically
define
supervision.
A
licensed
midwife
must
be
physically
present
on
the
premises
and
able
to
intervene
when
a
student
midwife
performs
any
clinical
tasks
at
births,
prenatals
or
postpartum
care
visit
visits.
Assistance
would
also
be
subject
to
this
rule.
This
is
a
matter
of
safety
for
families.
It
also
provides
protections
for
both
students
and
assistants
and
their
preceptors,
and
the
supervising
midwives
nacpm
supports
this
stance
on
direct
supervision.
Some
midwives
in
idaho
became
concerned
about
this
rule,
which
is
included
in
several
other
states,
licensure
laws.
B
B
If
a
student
does
not
perform
any
clinical
tasks
such
as
a
cervical
exam
check,
vitals
listening
to
fetal,
heart
tones,
etc,
and
they
are
only
there
to
provide
emotional
support
and
physical
comfort
measures,
basically
acting
as
a
birth
doula,
then
they
they
are
not
in
violation
of
the
nacpm
essential
doc
documents.
Any
clinical
assessment
of
the
client
without
supervision
is
a
violation
of
nacpm
essential
documents.
B
B
Details
have
not
been
completed,
but
requirements
would
not
be
extensive
or
complicated.
California
currently
requires
their
midwife
essence,
assistance
to
have
training
if
they
are
not
a
student
at
a
meek,
accredited
school.
I
know
there
are
concerns
that
this
would
limit
access
to
assistance
and
midwives
may
be
more
likely
to
attend
burst
alone.
Luckily,
especially
now
with
the
pandemic,
there
are
variety
of
online
assistant.
B
This,
in
turn,
has
been
shown
to
improve
outcomes.
We
want
to
provide
respectful
and
safe
care
to
our
nevada
families,
choosing
community
birth,
as
autonomous
providers
practicing
to
our
full
scope
and,
as
the
slide
says,
regulation
is
a
mechanism
by
which
the
social
contract
between
the
midwifery
profession
and
society
is
expressed.
Society
grants
the
midwifery
profession,
authority
and
autonomy
to
regulate
itself
in
return,
society
expects
the
midwifery
profession
to
act
responsibly,
ensure
high
standards
of
midwifery
care
and
maintain
the
trust
of
the
public.
B
A
F
Well,
I
guess
I
can
just
do
voice.
If
you
can
hear
me,
we
can
hear
you,
okay,
okay,
sorry,
I'm
on
a
loner
computer.
Today
I
apologize
well.
My
name
is
sarah
peters,
I'm
represent
assembly
district
24,
and
I
just
want
to
thank
assemblywoman
monroe
moreno
for
bringing
this
bill
and
I'm
honored
to
be
a
co-sponsor
and
co-presenter
of
ab387.
F
There's
been
a
lot
of
misinformation
circulating
about
the
genesis
of
this
bill
and
it's
unfortunate
that
a
community
made
up
of
a
value
system
designed
around
support
would
attempt
to
demonize
those
who
would
seek
to
enhance
access
and
financial
coverage
and
securities
to
a
greater
number
of
birthing,
see
people
in
our
state.
What
I
hope
today's
presentation
does
is
set
the
record
straight
regarding
the
intent
of
this
legislation
and
clear
the
names
of
those
attempting
to
address
these
basic
and
simple
issues.
F
I'm
a
home
birth
mother,
I
hired
a
midwife
for
all
three
of
my
births.
I
had
insurance
coverage
during
all
three
of
my
births.
However,
my
desired
service
was
not
covered
under
two
of
those
births
because
because
we
have
no
regulatory
certification
for
midwives
in
nevada,
the
third
one
wasn't
covered
because
of
an
insurance
loophole.
F
All
in
all
the
cost
of
birthing.
My
three
babies
at
home
was
more
than
out
of
than
out
of
pocket.
Minim
maximums
and
my
midwife
had
to
set
up
a
payment
plan
with
me
that
was
such
a
financial
burden.
I
almost
went
back
to
the
hospital
model
for
fear
of
inability
to
pay
my
other
bills.
I'm
going
to
check
my
privilege
here,
because
I
was
in
a
stable
financial
position
where
the
burden
was
real
but
absorbed
in
our
ability
to
quote
trim
the
fat
of
our
small
family
budget.
F
I
am
also
a
white
cisgendered
woman,
which
makes
it
easier
for
me
to
find
a
job
and
obtain
coverage
from
both
insurance
and
physicians,
so
I
always
had
a
back-up
plan.
Additionally,
my
family
is
local
and
supportive.
My
mother
used
the
same
midwife
who
birthed
my
children
when
she
birthed
me.
I
knew
that
if
I
ever
needed
help,
I
had
a
safety
net.
In
my
privilege,
not
every
birthing
person
is
so
lucky
around
60
of
birds
in
nevada
are
had
by
people
with
medicaid
insurance.
F
The
medicaid
provider
model
requires
providers
to
enroll
with
the
state
and
provide
credentialing,
although
there
are
some
exceptions,
medicaid
as
a
general
rule
requires
specific
credentialing
for
to
provide
reimbursement
for
services.
To
date,
nevada
has
no
such
recognized
credentialing
for
midwifery
or
other
support
services.
F
Only
40
percent
of
covered
are
covered
under
single-payer
or
company
plans
or
uncovered.
In
some
cases.
That
means
unless
the
birthing
person
can
pay
out
of
pocket
for
midwifery
services.
60
percent
of
birth
of
the
birthing
population
does
not
have
access
to
one
of
the
safest
ways
to
bird
their
baby.
F
Actually,
in
nevada,
25
of
birthing
people
do
not
receive
prenatal
care
at
all.
In
the
first
trimester,
eleven
percent
of
children
are
born.
Premature
and
nine
percent
are
born
with
low
birth
weight
at
delivery.
It
may
or
may
not
surprise
you
that
these
numbers
are
all
worse
than
the
national
average.
F
The
state
department
of
health
and
human
services
has
been
working
to
increase
these
outcomes
and
in
2020
had
a
goal
to
improve
prenatal
service
for
medicaid,
covered
pregnancies
by
10
and
fell
short
of
this
goal.
In
2020,
34
985
births
occurred
in
nevada
of
those
19
696
were
covered
under
medicaid,
the
cost
to
the
state
of
only
the
newborn
care
with
low
birth
or
low
birth
rate
weight.
Babies,
pre-term
babies
and
babies
needing
continued
services
was
51
million
668
621
an
increase
of
16
million
323
953
over
the
year.
F
We
know
this
is
not
a
money
committee,
but
I
think
it's
important
to
see
the
cost
to
the
state
when
discussing
alternative,
proven
birthing
model
access
in
2008,
a
2018
study
concluded
that
midwifery
care
and
low
risk
pregnancies,
reduced
preterm,
birth
and
labor
interventions.
The
study
also
cited
that
women
in
midwifery
care
were
less
likely
to
be
black,
have
medicaid
insurance
or
have
a
history
of
pregnancy,
complications
or
previous
caesarean
births.
Additionally,
women
in
midwifery
care
were
less
likely
to
end
up
having
a
pre-term
or
cesarean
birth.
F
All
of
these
outcomes
reduce
cost
of
care,
cesareans
being
one
of
the
highest
cost.
Birthing
scenarios
available
birthing
people
go
through
a
physical,
a
physically
trying
period,
conceiving
growing
and
birthing
a
child
takes
an
incredible
amount
of
work.
I
sometimes
joke
that
my
son
tried
to
kill
me
because,
while
pregnant
with
him,
I
was
so
sick.
I
don't
remember
a
day
during
that
pregnancy,
where
I
did
not
throw
up,
but
it
can
also
be
incredibly
rewarding
or
incredibly
traumatic.
I
got
to
witness
a
traumatic
birth
firsthand
in
college.
F
At
20
years
old,
I
got
to
hold
the
hand
of
a
friend
she
was
pregnant
covered
under
medicaid.
She
obtained
prenatal
care
from
a
physician
who
scheduled
her
birth.
When
I
asked
the
mother
about
this,
she
didn't
know
that
she
could
have
a
choice
to
go
into
labor.
Naturally,
the
doctor
induced
labor
by
giving
her
pitocin
there
was
no
reason
for
the
woman
to
go
into
labor
on
this
day.
Besides
that
that
that
was
the
birthing
model
of
her
care
provider,
I
would
be
lying
if
I
said.
F
I
remembered
everything
that
happened
that
day,
but
I
do
remember
that
pitocin
was
given
multiple
times
by
the
time
contract
contraction
started.
The
mother
mother
had
been
in
the
hospital
for
over
24
hours,
all
at
a
cost
to
the
state
when
she
went
into
labor.
Her
doctor
gave
her
an
epidural
which
then
made
her
so
numb.
We
had
to
tell
her
to
push
based
on
the
readings
of
a
monitor
and
a
screen.
The
doctor
used
every
intervention.
I
can
imagine
at
a
cost
to
the
state
of
what
the
doctor
used.
F
Oh
excuse
me,
there
was
no
need
for
this
level
of
intervention.
The
woman
didn't
know
she
had
choices
in
these
areas.
One
of
the
consistencies
of
this
discussion,
regardless
of
opposition
or
support,
has
been
the
idea
of
choice
that
birthing
people
deserve
choice
and
care
and
services
obtained
during
pregnancy,
birth
and
beyond.
The
current
single
model
of
covered
care
does
not
work
to
allow
for
those
choices
to
be
made
by
all
birthing
people.
F
F
C
C
Although
the
american
college
of
obgyns
believes
that
hospitals
and
birth
centers
are
the
safest
settings
for
birth,
we
recognize
that
each
woman
has
the
right
to
make
a
medically
informed
decision
about
where
they
deliver
and
who
their
provider
is.
Ab387
will
allow
licensure
of
qualified
midwives
in
nevada.
C
Women
who
choose
a
licensed
midwife
to
assist
them
with
their
birth
will
be
assured
that
their
midwife
has
met
the
requirements
set
forth
in
this
bill
and
have
agreed
to
practice
in
compliance
with
the
restrictions
listed.
The
bill
will
establish
that
women
who
do
not
meet
the
requirements
for
normal
low
risk
deliveries
pregnancies
will
be
informed
of
the
increased
risk
associated
with
their
diagnosis.
Ml
will
be
referred
for
consultation
or,
when
indicated
transferred
for
a
higher
level
of
care.
C
It
will
ensure
that
the
standard
of
care
based
on
current
science
is
consistent
for
women,
regardless
of
their
chosen
place
of
birth
or
their
chosen
provider.
A
working
group
that
will
form
after
the
bill
is
signed
into
law
will
promote
smooth
transitions
between
levels
of
care
as
tiffany
and
amanda
referred
to
earlier.
This
is
a
critical
point
of
of
contention
and
a
place
where
we
can
significantly
improve
outcomes
for
home
birth
people
who
choose
to
deliver
out
of
hospital.
C
C
A
D
Moreno
you
chair
heidegge,
and
thank
you
to
my
co-presenters
and
everyone's
patients
and
in
the
long
presentation,
but
it's
a
very
important
subject
matter.
D
D
So
in
section
3.8,
the
word
that
is
being
deleted
is
birth
assistance
and
it's
replaced
with
certified
professional
midwife
birth
assistant,
section
11.6
midwifery
is
replaced
with
certified
professional
midwife,
as
in
section
14.18,
cpm
student,
midwife,
section,
15.21
was
completely
deleted
by
the
amendment
section.
16.2
replaced
language
with
ap
rm
and
a
cnm
or
ob
with
experience
working
with
home
settings.
D
The
application
must
be
accompanied
by
a
fee
in
the
amount
prescribed
by
the
regulation
of
the
state
board
of
health,
and
it
goes
on
into
the
next
page
section
21
added
language,
which
is
the
cpm
in
section
21.1.2
and
0.3,
section
22.6
and
added
certified
professional
midwife
and
22.6
b,
certified
professional
or
certified
nurse
midwife,
section
22.63,
a
certified
professional
midwife,
section,
23.6
also
added
confirming
conforming
language
acid
24.43
in
25.24
there
was
language
that
was
replaced.
D
A
licensed
certified
professional
midwifery
was
the
wording
added
in
75,
section
75.44,
where
it
says
any
other
type
of
midwife.
That
was
that
language
was
removed
in
section
77.33,
the
language
was
added
of
cpm
and
certified
professional
midwife
in
the
final
two
sections
section,
101.16
and
102.1
added
language
to
the
bell.
A
C
Oh,
thank
you,
madam
chair.
I
just
wanted
to
take
a
minute
to
to
thank
assemblywoman,
moreno
and
swimming
woman,
peters
and
also
miss
hoffman,
for
what
I
believe
is
understated
in
how
long
this
has
been
worked
on,
and
I
I
think
we
have
been
receiving
emails,
suggesting
that
this
is
a
regional
issue
or
that
there
was
some
rush
just
on
policy.
C
I
don't
remember
exactly
when,
but
it
was
as
recent
as
2013
and
possibly
even
2011
when
this
first
came
up-
and
I
remember
distinctly
there
being
concerned
about
whether
or
not
the
community
was
ready-
and
there
was
a
period
of
time
where
the
midwifery
community
wanted
to
just
be
allowed
to
to
do
what
they
do
and
over
the
years
there
was,
I
think,
concern
growing
about
mortality
rates
in
childbirth
and
the
impact
it
had
on
communities
of
color,
and
I
just
wanted
to
make
sure
that
everybody
everyone
knew
this
was
something
that
has
been
contemplated
over
several
years,
literally
eight
to
ten
years
of
discussions
about.
C
C
Okay,
thank
you,
madam
chair,
and
thank
you
for
this
presentation,
as
in
so
many
build
presentations,
I
definitely
learned
a
lot
about
something
that
I
knew
very
little.
So
I
appreciate
that
so
just
trying
to
sort
this
out
from
how
I
understand
this
there's
a
meek,
education
and
then
there's
a
pet
pep
and
a
lot
of
midwives
in
our
state
currently
have
the
pep
education
and
then
this
bill
would
require
the
meek
education.
C
So
I
was
trying
to
write
down
the
the
requirements
quickly.
So
there's
you
know
like
a
three
year
program:
they
have
apprenticeships
a
clinical
requirement.
They
sit
for
credentialing.
E
Amanda
mcdonald,
for
the
record,
so
we
kind
of
talked
a
little
bit
about
that
that
u.s
mara
task
force
that
was
put
together
and
they
came
together
and
said.
Well,
how
can
we?
E
How
can
we
make
a
system
where
all
these
midwives
are
a
little
better,
integrated
and
a
little
bit
more
understood
about
where
they're
coming
from
and
they
decided?
You
know
what,
if,
if
these
midwives
had
a
really
standardized
education,
people
might
feel
a
little
bit
better
about
integrating
them
into
their
system.
I
know
when
I
speak
with
doctors,
sometimes
they're
really
nervous.
They
have
no
idea
what
our
level
of
education
is,
because
a
lot
of
midwives
go
through
that
pep
process
and
that
pep
process
is
really
individualized
and
yes
going
through
pep.
E
So
you
never
really
know
exactly
what
is
included
in
a
pep
education,
because
it's
kind
of
like
self-study
and
there's
a
lot
of
information
out
there,
and
I
know
a
lot
of
amazing
pep
trained
midwives
for
sure,
but
the
idea
of
the
meek
accreditation
program
is
that
it's
standardized,
there's
no
questions
about
who
got
what
and
when
and
how
it's
meek
does
this.
They
have
to
be
accredited,
they
have
to
meet
these
standards.
This
is
the
education
they
get.
This
is
the
process
they
go
through.
This
is
the
paperwork
they
do.
B
And
it
has
been
presented
as
a
important
and
non-negotiable
piece
for
collaboration
and
integration,
so
that
and
as
we
see
that
that
improves
outcomes,
and
so
that's
why
it's
important.
C
F
Remember
hardy,
we
don't
have
I'm
sorry
chair.
This
is
sarah
peters.
I
just
wanted
to
add
that
this
bill
doesn't
un,
doesn't
obligate
every
midwife
to
this
education
track
it's
only
for
midwives
who
would
obtain
or
choose
to
obtain
that
certification.
C
E
So
those
midwives
who
already
have
their
cpm
through
that
pep
process
requirements
for
licensure,
would
be
that
midwifery
bridge
program
that
we
talked
about
that
middle
free
bridge
certificate
with
the
extra
50
ceus,
so
they
would
have
their
their
cpm
credentialing.
That
happened
through
the
north
american
registry
of
midwives,
based
on
their
pep
education,
passing
their
exam.
Getting
through
all
the
skills
checks,
then
they
would
get
that
middle
free
bridge
certificate
and
then
they
would
be
eligible
to
apply
for
licensure
here
in
nevada.
E
I
know
a
lot
of
the
cpms
who
are
pep
trained
either
have
their
midwifery
bridge
here
already
or
they
are
working
on
it
currently.
So
it's
a
matter
of
finishing
that
up
and
by
the
time
they
do
chances
are
that's
going
to
be
when
we're
starting
to
do
all
this
paperwork
and
get
things
going
hopefully,
so
it
would
not
mean
that
they
have
to
go
back
to
school
and
get
a
pep
education
they
have
to.
E
B
We
have
we've
put
a
piece
in
the
bill
that
would
would
allow
individual
extensions
to
that
date
for
rural
midwives
and
midwives,
who
represent
communities
that
are
have
been
historically
marginalized.
So
we
want
to
make
sure
that
we
create
a
more
diverse
midwifery
workforce.
D
And
I'm
madam
chair,
this
is
assemblywoman
monroe
moreno,
that
additional
time
would
be
on
a
case-by-case
basis
and
the
the
board
would
be
able
to
to
look
at
those
on
a
case-by-case
basis
if
they
had
to
be
extended.
D
But
there
was
a
lot
of
conversation
from
some
other
midwives
that
there
are
not
a
large
number
of
midwives
from
communities
of
color
or
in
their
rural
communities,
and
they
were
finding
it
difficult
to
get
the
training
and
that's
why
the
extension
was
put
in
the
amendment
and
giving
the
board
that
ability
to
do
things
on
a
case-by-case
basis.
C
E
Chair
and
thank
you
so
much
for
the
presentation
and
the
bill.
My
question.
A
E
E
So
you
can
do
your
your
three
years
of
didactic
study
more
quickly
than
that,
if,
if
you
can
but
generally
bare
minimum
bare
bare
minimum
is
two
years
in
this
program
we
often
see
cpms
taking
much
longer
than
that.
It's
really
common
because
it
depends
on
how
many
people
are
having
babies
out
of
the
hospital
in
your
community.
E
What's
your
availability
for
preceptors,
you
know:
what's
your
family
structure?
Look
like
d?
Are
you
able
to
be
a
full-time
student
and
attend?
You
know
five
birds
a
month?
Can
you
only
attend
two
birds
a
month,
so
it
really
depends
on
how
long
it
takes
you
to
get
those
clinical
skills
really
buttoned
down
and
finish
that
didactic
portion
if
you're
doing
distance
learning
some
of
those
microphones
are
distance,
learning
and
those
you
can
work
around
your
schedule
a
little
bit
differently.
Then
I
have
to
travel
to
my
school.
E
That's
on
a
much
more
set
schedule,
so
there's
a
lot
of
different
factors
in
there.
I
can
speak
for
meek
education.
Some
of
those
programs
are,
I
want
to
say
the
three.
The
least
expensive
was
probably
I
wanna
say
nine
thousand
dollars,
and
there
are
some
well
up
into
the
tens
and
tens
of
thousands
of
dollars.
So
it
really
depends
on
the
program
really
is
dependent
on
on
how
you're
going
through
things
with
your
preceptors
some
preceptors
charge
a
fee.
Some
do
not.
Some
student
midwives
are
paid
by
their
preceptor
for
attending
birds.
E
Some
are
not.
There
are
scholarships
available
for
meek
programs
and
grants
as
well.
I
don't
think
there's
any
well.
There
might
be
some
scholarship
out
there
for
for
pet
programs
as
well,
but
usually
usually
they're,
going
towards
the
meek
schooling.
So
it
very
much
varies
depending
on
on
your
path
and
what
you're
doing.
A
C
Thank
you
so
much
chair
it,
it
kind
of
seems
like
we're,
placing
some
burdensome
training
requirements
on
birth
assistant
that
actually
only
provides
support
during
birthing
overseen
by
a
qualified
midwife.
C
Should
this
bill
pass
the
way
it
is,
do
you
think
that's
going
to
place
a
rural
midwives
at
a
severe
disadvantage.
B
Tiffany
hoffman
for
the
record
honestly,
the
the
training
for
oops,
sorry,
the
training
for
assistance
is,
is
not
extensive
and
it
is
not
burdensome
and
honestly.
So
when
we
attend
bursts
in
the
home,
setting
attending
alone
is
not
is
not
generally
the
safest
way
to
attend
to
birth.
If
there
is
a
complication
that
arises
during
that
birth,
and
so
that
assistant
is
there
as
a
medical
as
a
medic
as
a
clinical
assistant,
and
so
that
person
will
have
to
be
responsible
for
clinical
tasks
and
sometimes
that
include
the
resuscitation
of
a
newborn.
B
It
might
be
giving
medications
for
a
hemorrhage,
that's
occurring.
It
might
be
cpr
to
a
mother
or
a
birthing
person,
and
so
that
person
has
to
be
well
trained
in
in
some
way
fashion
or
form.
So
having
someone
who
was
untrained
or
just
started
attending
verse
then
has
had
zero
training
whatsoever.
Learning
on
the
job
in
this
case
probably
isn't
the
best
way.
Yes,
you
will
learn
as
you
intend
first,
but
you
need
to
have
some
basic
foundational
level
of
education
or
training
before
you
start
attending
birth
in
that
assistant,.
C
And
chair
could
do
we
have
time
for
me
to
have
a
second
question
or
no
yes,
assembly
member
go
ahead.
Thank
you
so
much.
So
what
is
the
restriction
on
someone
who
moves
to
nevada
as
far
as
experience.
B
I
tiffany
hoffman
for
the
record,
I
believe
you're
you're,
referring
to
the
reciprocity
agreement
yeah.
It
is
currently
listed
as
five
years.
You
know
we
we're
we're
open
to
changing
that
if,
if
necessary,
that
wasn't
a
piece
that
we
were
strongly
tied
to.
So,
if
that
were
something
that
seemed
to
be
burdensome,
we
would
be
absolutely
willing
to
change
that.
C
D
Your
heidi
game,
yes
hi.
This
is
assemblywoman
monroe,
moreno
in
response
to
assemblywoman
dickman's
question.
I
I
appreciate
your
comments.
However,
the
training
that
a
midwife
would
receive
in
another
state
coming
to
our
state.
If
she
she
or
he
wanted
to
be
a
midwife
in
this
state
and
have
a
license,
they
would
have
to
meet
the
standards
of
this
state.
So
if
their
licensure
in
another
state
was
less
than
nevada,
they
would
have
to
meet
the
standards
of
nevada.
C
Assemblywoman
dickman
for
the
record
yeah.
I
think
that
makes
perfect
sense,
but
could
we
speed
it
up
if
they
do
have
the
same?
Require
your
qualifications.
C
To
get
that,
I
forget
what
the
mea
and
mac
they
have
to
have
still
have
to
show
and
have
someone
monitor
them
during
five
births.
Is
that
correct?
Did
I
misunderstand
that.
C
I
don't
even
know
we
have
them
out
in
the
world
such
as
tonopah,
who
is
pep
now
and
has
been
active
for
several
years
qualified
I
guess
under
the
cab
to
convert
over.
Does
she
have
to
have
you
come
monitor
her
or
monitor
her
five
deliveries.
E
For
the
record,
sorry,
so
if
it's
someone
who
has
been
practicing-
and
they
are
not
a
certified
professional
midwife
right
now-
they
could
continue
to
practice
just
like
they
are
right
now
and
just
not
opt
to
get
a
license
and
continue
exactly
what
they're
doing
right
now
you
know
other
than
letting
their
their
client
know
that
hey!
I
don't
have
a
license
in
this
state.
E
If
it
is
a
student
who
is
working
towards
their
cpm
or
is
trying
to
become
a
certified
professional
midwife,
they
do
need
to
be
overseen
by
a
preceptor
who
is
a
certified
professional
midwife.
The
number
of
birds
that
they
have
to
attend
are,
I
think,
we're
up
to.
I
want
to
say
55.
E
They
have
to
attend
overseen
many
attend
more
than
that,
just
because
their
apprenticeship
may
take
longer,
and
so
it
really
depends
on
what
route
they're
going.
Are
they
going
to
remain
unlicensed?
If,
if
they
plan
to
do
that,
there's
there's
no
changes
that
they
have
to
do.
They
don't
have
to
be
supervised.
If
they're,
a
student
planning
on
getting
their
cpm
they're
going
to
need
to
be
supervised.
B
And
tiffany
hoffman
for
the
record,
if
this
is
a
cpm
that
would
like
to
qualify
for
licensure
in
the
state
of
nevada,
the
bridge
certificate,
if
they
are
currently
a
cpm
having
gone
through
the
pep
route,
the
only
thing
they
would
require
is
the
bridge
certificate,
which
is
that
50
ceus
that
they
have
five
years
to
complete.
I
think
we
have
it's
four
years
right
now
with
what
we
have
in
our
in
our
bill.
It
would
be
available
until
2025.
C
A
Okay,
I
do
have
one
assembly,
member
monroe,
moreno
for
you
or
your
presenters,
and
it's
regarding
the
amendment.
I
noticed
that
you're
completely
deleting
section
15
and
I
just
kind
of
wanted
you
to
walk
us
through
what
the
intent
was
behind
that
I
know
that
section
15
disaster,
that
kind
of
gave
people
the
authorization
too.
If
they
didn't
want
to
get
the
licensure,
did
you
just
provide
a
document
saying
that
they
weren't
a
licensed
that
they
weren't
licensed
and
then
also
the
requirement
for
them
to
keep
the
records?
A
D
So
I
will
start
off.
This
is
assemblywoman
monroe
moreno
and
I
will
throw
it
over
to
the
midwives
that
are
on
the
presentation
doing
meetings
with
other
midwives
in
our
state.
It
was
brought
to
our
attention
that,
having
that
section,
kind
of
set
them
apart
and
had
two
classes
of
midwives,
that
the
midwives
who
were
not
licensed
were
the
only
ones
being
obligated
to
have
this
form
and
save
it
for
five
years.
D
We
thought
it
would
be
better
to
treat
everyone
as
equal
and
so
that
everyone
would
have
the
form
letting
their
clients
know
what
type
of
midwife
there
are
that
are
available
in
the
state
and
not
setting.
Anyone
aside,
it
would
be
all
midwives
would
have
the
form
just
an
informed
consent
for
their
clients,
and
so
that's
why
that
section
was
taken
out
just
to
make
the
bill
more
equitable,
because
we
know
not
every
midwife
in
the
state
wants
to
have
a
licensure,
and
we
didn't
want
to
impede
upon
that.
A
And
that
that
leads
me
to
my
second
question
so
then
again
I
mean
this
is,
if
I
write
it
correctly,
this
is
completely
option
optional.
Certified
midwife
can
choose
to
get
the
license
or
choose
not
to
get
the
license.
D
C
Thank
you,
chair
and,
and
that
did
I
do
appreciate
that
you
asked
that
question
about
that
section,
because
I
I
too
was
wondering
about
that
and
that's
put
on
another
question.
So
is
what.
C
For
those
who
are
licensed
versus
those
who
are
not,
I
know
that's
kind
of
the
cusp
of
this
whole
bill,
but
is
it?
Is
it
that
medicaid
or
medicare
coverage
medicaid
coverage?
Is
it
if
we
could
just
sort
of
chart
it
out
as
just
summarizing
the
overall
presentation
to
make
it
clear
in
my
head?
That
would
be
helpful.
D
I'm
going
to
start
I'm
going
to
start
and
then
I'm
going
to
ask
tiffany
and
amanda
to
take
over.
As
I
said
in
my
opening
statements,
there
were
constituents
in
my
district
and
other
districts
that
came
to
me
that
had
negative
outcomes
with
their
midwives
that
they
had
hired
thinking
that
the
state
of
nevada
had
a
licensure
and
when
they
found
out
that
there
wasn't,
they
asked.
How
can
we
set
up
that
licensure?
There's
been
some
amazing
outcomes
with
midwives.
D
I'd
say
more
than
90
percent
of
the
the
first
with
midwives
have
wonderful
outcomes,
but
you'll
hear
from
some
people
who
are
will
be
joining
us
in
support
and
opposition
of
this
bill.
You'll
hear
stories
of
some
of
the
negative
outcomes,
so
they
asked
of
me
was
how
can
we
provide
that
licensure?
How?
How
can
we
establish
regulations
and-
and
it's
you
heard
from
assemblywoman
peters
in
utilizing
her
midwife,
she
wasn't
able
to
use
for
insurance.
D
E
Amanda
mcdonald,
for
the
record,
so
this
is
like
the
big
part
of
the
conversation
that
that
people
go
back
and
forth
about
like
why
on
earth
would
you
want
to
have
licensure
if
you
are
living
in
a
state
and
practicing
in
a
state
that
does
not
require
it?
Why
would
you
subject
yourself
to
the
state
coming
into
your
practice
and
telling
you
what
to
do
so?
E
There
are
two
sides
to
this
and
I'll
kind
of
start
from
the
unlicensed
side.
Midwives,
who
choose
not
to
be
licensed,
don't
have
the
state
overseeing
their
rules,
so
they
have
full
autonomy
with
their
with
their
families
and
their
clients
to
make
those
decisions
that
feel
best
for
those
families,
and
that
may
not
be
the
same
as
the
boundaries
that
other
midwives
might
feel
comfortable
with,
but
they
don't
want
to
be
restricted
by
the
rules
of
licensure,
so
they
will
choose
streaming
and
license
because
they
want
that
freedom.
They
value
that
freedom.
E
It
serves
their
communities
best
and
that's
what
they
feel
really
comfortable
doing
and
those
are
the
midwives
that
those
families
feel
really
comfortable
hiring
those
midwives
on
the
licensure
side.
Yes,
there
are
restrictions
that
come
with
licensure.
We
know
that
to
be
the
case,
but
there's
also
a
lot
of
positives
accountability.
That's
a
huge
one.
E
So
if
a
licensed
midwife
is
practicing
in
a
way
that
is
negligent
or
unacceptable
or
or
needs
to
be
adjusted,
there's
a
process
for
that
and
there's
there's
a
way
to
to
work
through
those
issues
and
and
get
that
sorted
out.
Collaboration
is
a
huge
piece.
We
talked
about
the
safety
issues
and
one
of
the
ways
of
making
out
of
hospital
birth,
safer
is
by
collaboration
and
integration.
E
We
have
medical
professionals
who
are
really
really
nervous
about
collaborating
with
out
of
hospital
midwives
because
we
are
not
licensed,
I
hear
it
over
and
over
and
over
again
we
don't
know
what
kind
of
education
you
have.
We
don't
know
where
your
boundaries
are.
We
don't
know
how
you're
practicing.
We
don't
know
what
your
charting
looks
like.
So
when
you
have
something
with
some
set
standards,
other
professionals
have
an
idea
of
okay.
This
is
what
this
group
of
midwives.
This
is
the
norm
for
them.
This
is
what
we
can
expect.
E
Access
is
huge
right.
We
talked
about
the
financial
benefits.
Being
able
to
accept
insurance
from
clients
more
easily
is
is
really
really
helpful.
I
always
get
really
excited
when
I
find
out
that
my
my
families
are
able
to
fully
utilize
their
health
insurance
benefits.
I
have
pretty
decent
luck
because
I
am
licensed
in
the
state
of
california
so
that
helps
out
a
lot
in
the
state
of
california.
E
I
don't
practice
over
there
very
often
so
I
haven't
gone
through
the
process
because
it
would
be
expensive
for
me-
and
I
don't
have
many
medi-cal
clients
over
on
the
california
side,
but
you
can't
do
that
if
you
don't
have
a
license
so
that
access
for
families-
I
don't
know
you
guys,
heard
the
birth
center
bill.
If
birth
centers
come
about
in
this
state,
we
will
not
be
able
to
work
and
then,
unless
we're
licensed,
and
so
that's
an
access
issue
for
families.
E
If
there
are
birth
centers,
who
are
run
by
certified
professional
midwives
who
are
licensed
in
the
state,
that's
access
for
family,
some
families
don't
want
to
have
babies
in
their
home
and
they
feel
more
comfortable
in
a
birthing
center
setting.
So
that
is
huge
referrals.
This
one
is
kind
of
like
back
and
forth.
While
this
this
licensure
would
not
require
that
any
provider
collaborate
with
us,
we
cannot
require
that
they
do
that.
E
It
might
open
the
doors
to
you
know
bridging
that
gap
between
okay
I'll
go
ahead
and
see
one
of
your
clients.
I
I've
never
done
this
before
and
I'm
a
little
bit
nervous
about
it,
because
this
is
very
different,
but
now
that
we
have
some
sort
of
guidelines
and
some
sort
of
regulations,
this
this
relationship
might
be
easier
on
both
sides.
So
there's
there's
pluses
to
licensure
there's
downsides
to
licensure.
E
There
may
be
some
restrictions
that
people
don't
like
to
see,
but
those
are
things
that
the
board
would
come
up
with
and
being
unlicensed
is
is
really
similar
to
what's
happening
right
now.
So
if
someone
is
absolutely
okay
with
the
way
that
their
practice
is
going
right
now
and
the
families
are
absolutely
happy
with
the
care
they're
receiving,
they
can
continue
to
go
down
that
unlicensed
path.
A
Okay,
just
to
give
everyone
listening
over
the
internet,
the
lay
of
the
land
of
what
testimony
will
look
like.
I
will
be
taking
30
minutes
of
testimony
and
support
30
minutes
of
testimony
in
opposition
and
30
minutes
of
testimony
in
neutral.
I
do
have
a
couple
of
people
who
have
signed
up
signed
up
and
are
going
to
be
testifying
on
video,
so
we
will
start
with
them
and
then
move
over
to
the
telephone
lines
and
then
transition
into
the
next
part
of
the
testimony.
A
With
that
I
will
be
moving
us
into
testimony
and
support.
I
know
we
have
missed
danielle
yeager
on
with
us
on
zoom,
if
you'd
like
to
just
unmute
yourself,
miss
yeager,
to
give
yourself
the
opportunity
to
give
your
testimony
and
support
of
the
assembly
bill.
F
We
didn't
know
there
was
a
difference
between
midwife's
education,
which
there's
a
lot
of
different
types
of
midwives.
You
think
they're
all
the
same
they're,
not
we
thought
we
actually
hired
a
nurse
midwife
as
we
as
it
turned
out.
We
hired
somebody
who
was
actually
criminally
charged
in
california
for
practicing
out
with
without
a
license
where
a
baby
almost
died
under
her
care.
We
didn't
know
any
of
this
until
after
her
son
died,
so
she
left
california,
which
is
a
licensed
state,
came
to
nevada.
Where
we
have
no
regulations
and
continued
practicing.
F
We
tried
to
file
a
complaint.
We
contacted
as
many
different
boards
in
the
state
to
let
them
know
what
happened,
but
there's
nobody,
there's
no
oversight.
Here.
We
have
nothing,
and
since
there
was
nothing
to
do,
there
was
no
way
to
hold
her
accountable
to.
Let
anybody
know
what
she
had
done.
We
couldn't
make
anything
aware:
we
need
to
have
something:
some
type
of
oversight,
some
type
of
board.
Some
type
of
regulation
put
to
keep
them
ethical
to
keep
them
on
par
with
what
we
have.
F
I
support
this
much
needed
and
long
time
coming
bill
to
give
education
to
midwives,
to
hold
them
accountable,
to
make
student-wise
midwives
getting
make
sure
they're
getting
the
proper
care
because
you
don't
want
them
alone
on
the
job.
Just
like
you
wouldn't
want
somebody
alone
on
the
job,
that's
learning
and
has
no
idea
what's
going
on
when
this
has
to
do
with
birth.
We
just
don't
know
they
could
misdiagnose.
F
I
do
agree
with
the
past
that
the
midwives
working
with
the
hospitals
and
the
medical
staff
that
is
very,
very
important
for
making
assessments
for
risking
people
out
and
transfers
safer
and
easier.
Because
boy
do.
I
wish
that
I
had
that,
because
my
life
would
be
completely
different
if
we
had
the
proper
assessments
by
a
doctor
and
the
transfer
plan
that
was
actually
put
in
motion.
F
No
one
ever
expects
something
to
go
wrong,
but
having
the
proper
care
with
the
teams
ready
and
available
working
together
makes
all
the
difference
between
life
and
death.
Choice
means
safety
by
giving
better
and
improving
care
without
the
accountability,
updating
education
and
bridge
between
out
of
hospital
and
hospital
care.
Our
state
is
lacking
safety
care
and
informed
consent,
which
means
there's
really
no
real
choices
for
women
and
their
families.
F
Our
our
state
has
seen
hard
times
really
really
hard
times
with
kovid,
and
many
families
are
looking
to
other
birth
options
to
keep
their
family
safe
from
the
virus.
Creating
regulations
by
building
a
more
open
relationship
between
out
of
hospital
and
hospital
care,
especially
during
this
time
and
for
the
the
upcoming
future,
is
how
we
keep
families
in
our.
It
is
our
right
as
nevada
citizens
to
be
given
better
and
safer
choices.
That
means
bumping
up
or
out
of
hospital
providers
with
the
necessary
regulations
and
to
get
a
proper
level
of
care
for
everyone.
F
F
It
really
really
truly
matters,
because
if
they
don't
have
the
proper
education,
they
miss
red
flags
that
could
be
sending
to
the
hospital
that
could
literally
save
their
child
or
their
selves.
So
that's
that's
all.
I
have
to
say
and
thank
you
for
listening
and
thank
you
for
having
this
board
and
all
this
stuff.
Thank
you.
A
C
C
G
Hello,
can
you
guys
hear
me?
Yes,
we
can.
G
My
name
is
erica
miniberry
and
I
am
testifying
in
support
of
ab387,
because
in
2013
I
had
a
home
birth
that
ended
in
a
hospital
transfer
that
ended
in
a
cesarean
section.
My
midwives
took
incredible
care
of
me
and
exercised
the
utmost
in
safety,
including
my
mental
health.
I
had
a
beautiful
healing
birth
despite
the
c-section
because
of
this.
If
my
midwives
had
put
their
own
biases
and
agenda
before
the
safety
of
my
baby
and
myself,
I.
H
You
are
about
to
hear
a
bunch
of
testimonies
in
opposition
to
this
bill
from
birth
workers
who
do
just
that
put
their
own
self-interest
before
the
safety
of
their
client
in
the
name
of
big
teen
freedom,
outside
of
the
fact
that
this
bill
does
not
impact
the
freedom
of
anyone.
I
do
wonder
if
these
opposers
consider
the
freedom
of
the
black
parents
and
babies,
who
are
dying
at
up
to
six
times
the
rate
of
their
white
counterpart.
H
C
H
H
I
called
9-1-1
on
february
17th,
just
after
3
am
my
third
child
was
had
been
born
at
home
and
was
born
virtually
lifeless
after
a
minute
or
two
of
cpr
and
oxygen,
which
felt
like
an
eternity.
The
baby
was
still
unresponsive
and
the
midwives
instructed
me
to
call
the
ambulance.
H
This
was
a
very
different
birth
than
the
the
first
two
births
of
my
other
children.
Her
first
one
was
born
in
the
hospital,
and
the
birth
was
fine,
but
the
afterwards
or
the
constant
check-ins
and
monitoring
the
trash
collection
and
the
kind
of
general
hubbub
of
the
hospital
we
just.
We
found
it
impossible
to
rest.
So
we
had
a
hope.
Excuse
me:
we
had
a
home
birth
for
our
second
child
and
that
home
birth
went
just
fine
and
afterwards
it
was
lovely
to
be
home,
our
own
bed,
our
own
food,
the
family
around
it.
H
It
was
just
great
so
our
third
baby
aaron
not
to
bury
this
too
far
down.
He
is
now
happy
he's
healthy,
he's,
just
an
impossibly
naughty
and
willful
little
one-year-old.
The
issues
that
he
faced
at
birth
were
total
statistical,
aberration
and
nothing
to
do
with
our
midwives,
and
we
feel
like
home.
Birth
families
in
the
future
should
know
that,
or
on
the
flip
side
they
should
know
if
there
was
an
issue
that
was
the
fault
of
or
the
the
negligence
of
the
midwives,
with
common
sense
regulations
and
reporting
standards
of
education
and
certification.
H
More
families
in
the
future
can
feel
comfortable
to
have
the
kind
of
lovely
experience
we
had
at
least
with
our
second
child
licensure
and
mechanisms
for
correcting
issues
or
revoking
the
license
are
much
needed
to
ensure
safety
and
transparency.
Our
midwives,
ms
hoffman
and
mrs
mcdonald,
who
you've
been
hearing
from
this
evening,
kept
aaron
alive.
They
were
professional,
they
were
quick.
They
were
100
on
top
of
that.
H
H
They
just
didn't
know
what
the
level
of
training
and
expertise
certificate
they
didn't
know
what
they
were
walking
into,
and
this
is
the
other
main
reason
that
I
support
this
bill
that
the
provisions
that
would
recognize
this
as
a
profession
and
create
a
system
for
working
with
to
make
sure
the
first
responders
know
when
they're
dealing
with
trained
professionals
and
able
to
administer
life-saving
care
much
more
quickly.
Again,
thank
you
for
letting
me
speak,
and
I
urge
your
support
for
ab387
and
I'd,
of
course,
be
happy
to
answer
any
questions.
C
G
G
G
In
fact,
she
was
over
an
hour
away
and
the
client
was
pushing
I
caught
the
baby
by
myself
and
when
the
mother
hemorrhaged,
the
midwife,
instructed
me
to
inject
pitocin
in
a
manner
that
has
not
been
practiced.
Since
the
70s
I
needed
my
primary
midwife
there.
This
client
needed
the
primary
midwife
there.
The
client
deserves
better.
G
A
licensed
midwife
should
be
at
all
appointments,
labors
and
births.
A
student
should
never
have
to
experience
this
alone
until
they're,
ready
and
properly
educated,
and
this
outdated
advice
the
midwife
gave
me
should
have
been
brought
to
attention
at
a
peer
review,
so
others
could
educate
her
on
new,
evidence-based
practice.
G
As
a
midwifery
student,
I
have
also
witnessed
the
disconnect
between
midwives
and
hospital
staff.
I
can't
express
how
important
it
is
for
me
to
have
the
opportunity
to
create
and
cultivate
relationships
with
doctors,
specialists
and
hospitals
to
help
keep
birthing
people
and
babies
safe
and
on
the
topic
of
keeping
birthing
people
and
babies
safe.
As
a
student,
I
also
want
to
be
able
to
have
access
to
life-saving
medications
and
other
equipment
at
first
that
I
attend.
G
A
C
C
H
H
I
began
practicing
in
nevada
in
1999
on
the
labor
floor
at
nellis
air
force
base,
our
four
ob
gyn
physicians
worked
collaboratively
with
two
certified
nurse
midwives
and
truly
enjoyed
our
working
relationship,
sharing
low
risk
and
high
risk
patient.
That
is
safe
and
effective
environment,
and
I
learned
a
great
deal
from
these
midwives.
H
When
I
answered
private
practice
in
las
vegas
in
2003,
I
immediately
began
seeing
home
midwife
delivery
patients
transferred
to
hospitals.
Typically
when
complications
from
childbirth
had
already
occurred.
Through
my
national
involvement
with
acog,
I
have
watched
other
states,
research,
the
need
for
proper
education
and
licensure
of
home
midwives.
The
professional
degree
of
cpm
became
a
standard
term
in
the
midwife
field.
There
had
to
be
a
way
for
apprenticeship,
trained
and
direct
entry
midwives,
who
did
not
go
through
masters
or
nursing
master's
degree
training
to
continue
the
practice
as
midwives.
H
This
was
thoroughly
reviewed
in
the
cpm
powerpoint
presentation.
We
just
heard
we
have
always
known
that
midwives
have
been
performing
home
births.
The
standards
endorsed
for
licensure
allowed
these
midwives
to
meet
the
international
standards
we've
heard
described
through
the
icm
and
meek
and
through
all
of
your
questions
during
the
question
session,
it's
time
for
nevada
to
uphold
the
standards
from
mcwifery
care
expected
by
women
in
other
nations
and
around
the
world.
H
You
will
hear
opposing
views
that
giving
birth
is
a
natural
physiological
process
that
has
been
intended
to
for
centuries
by
midwives,
and
I
agree
that
birth
is
a
natural
physiological
process.
But
you
know
what
else
is
well
I'll
start
with
this
one
digestion,
because
I
know
I'm
hungry
right
now
and
I'm
sure
many
of
you
are
skipping
meals
right
here
tonight
and
when
natural
physiological
processes
go
wrong
or
cause
disease,
our
public
relies
on
trained
and
licensed
gastroenterology
specialists
to
care
for
them
another
example
the
beating
of
our
hearts
and
the
circulatory
system.
H
H
A
G
G
One
of
my
roles
was
actually
auditing
software
at
nasa
at
their
alabama
location.
I'm
a
former
unit
clerk
for
intensive
care
nursery.
I
have
an
associate's
degree
in
science,
healthcare
management
at
science,
for
health
care
management
and
I'm
a
former
medical
biller
encoder.
I
have
three
biological
children
and
the
first
one
was
born
with
vanderwood
syndrome.
I
attended
ob
gyn,
as
you
know,
as
stated,
nothing
was
wrong,
didn't
know
she
had
vanderwood
syndrome
and
had
been
born
without
a
soft
palate
until
she
was
three
months
old
and
I
was
administering
cpr
in
my
living
room.
G
My
second
was
a
very
traumatic
c-section.
He
was
born
six
weeks
premie
and
following
that
I
joined
the
united
states.
Army
got
a
healthy
dose
of
ptsd
due
to
us
military
sexual
trauma
and
then
met
tiffany
hoffman.
When
I
was
pregnant
at
the
age
of
36.
With
my
third
born
it's
my
first
time
I
breastfed
it's
my
first
time.
I've
been
with
a
midwife,
and
I
know
why
they
say
time
with
a
patient,
though
it's
a
different
level
of
relationship,
and
it
allows
you
to
practice
skills.
G
The
highest
rate
of
child
abuse
in
the
under
federal
guidelines
is
under
age.
One
is
25.7
and
an
annual
estimate
of
1
840
children
die
from
abuse
and
neglect,
and
that
was
as
of
2019.
G
Then
I
will
draw
your
attention
to
childwelfare.gov
and
their
how
their
public
health
approach,
a
number
of
experts,
have
championed
a
public
health
approach
to
addressing
child
maltreatment
fatalities,
which
focuses
on
improving
health
and
well-being
of
individuals
and
communities.
Before
child
maltreatment
happens,
a
public
health
approach
involves
defining
the
problem,
identifying
the
risks
and
protective
factors,
understanding
consequences
and
developing
prevention
strategies.
G
C
H
Hi
there,
my
name
is
zach
chatel,
v-a-c-k
c-h-a-t-e-l-l-e,
thanks
for
having
me
I'll
try
to
be
brief.
H
We
had
two
certified
midwives,
one
being
the
main,
and
our
experience
was
amazing.
It
didn't
go
to
plan.
We
ended
up
having
to
go
to
the
hospital
later
in
the
pushing
phase
of
of
labor,
which
was
the
call
of
our
midwife,
which
was
greatly
appreciated
because
of
the
work
that
our
midwife
had
done
in
building
a
network
and
relationship
with
the
hospitals
she
was
able
to
advocate
for
us
before
we
ever
got
there
all
our
information.
Our
needs
were
there.
H
They
knew
that
we
were
going
for
a
natural
style
birth,
and
so
that
was
kept
in
mind.
We
had
an
overall
great
experience
as
a
paramedic
accreditation
to
me
just
means
continuity
of
care
for
our
patients,
and
that
should
be
every
clinician
at
any
level's
goal.
H
We
want
the
best
outcome
for
our
patients
and
when
we
all
have
a
uniform
standard
of
care,
we
all
can
rely
on
each
other
and,
and
one
of
the
people
talked
earlier
and
said
that
you
know
we
can
assume
our
job
and
take
action
sooner
when
we
don't
have
to
re-follow
steps
that
have
already
been
taken
and
kind
of.
My
ending
point
is
just
that
hospitals
are
for
everything
else.
H
C
C
G
G
G
The
hospital
staff
had
a
strong
relationship
with
my
midwives
and
more
kind
and
encouraging
to
me
upon
arrival.
I
received
amazing
prenatal
care
with
each
of
my
prenatal
visits
with
tiffany
being
60
minutes
long,
and
she
ensured
that
I
was
as
healthy
and
felt
as
supported
as
possible
and
then,
after
my
daughter,
was
born.
Tiffany
made
five
one
hour,
postpartum
visits
to
her
home
within
the
first
six
weeks
to
ensure
my
daughter
and
I
were
healthy
and
that
we
were
adjusting
to
our
new
family
life.
G
So
this
is
not
the
standard
that
caramel
bursting
people
receive,
but
it
should
be
available
to
anyone,
regardless
of
a
person's
financial
resources.
I
strongly
support
83
d7
because
it
would
greatly
expand
availability
of
safe
of
hospital
birds
in
our
state
and
would
ensure
the
safety
of
birthing
people
and
their
babies.
Thank
you.
So
much.
C
H
Good
evening
my
name
is
kendria
k-e-n-d-r-e-I-a
dickens,
I'm
a
board-certified,
obstetrician
gynecologist
in
las
vegas.
I've
been
practicing
in
nevada
since
2004.
I
started
out
originally
in
a
rural
city,
known
as
mesquite
nevada.
I
practice
currently
as
an
obstetric
laborist,
which
is
a
physician,
an
ob
gyn
board
certified
who
practices
solely
in
the
hospital.
H
H
We've
taken
care
of
many
women,
who've
had
conditions
and
risk
factors
which
would
not
at
all
be
ideal
for
home
birth.
These
are
this
will
include
women
attempting
breach
deliveries
at
home
trials
of
labor
after
cesarean
sections
coming
in
with
ruptured
uteruses
home
deliveries
of
women
with
complex
medical
conditions,
of
which
my
team
in
the
last
month
have
witnessed
two
babies
that
have
been
dead,
as
a
result
of
you
know,
attempted
home
births
with
conditions
that
were
really
high
risk
for
the
record.
H
I'm
I'm
truly
an
advocate
for
women
and
believe
that
women
have
the
right
to
choose
their
birth
experience.
I
do
believe
that
they
also
need
to
be
very
aware
of
the
education,
training
experience
and
any
past
disciplinary
actions
taken
against
any
provider.
Unfortunately,
in
our
state,
midwifery
has
not
been
pretty
much
regulated
in
that
same
way,
they
have
not
been
held
to
the
same
types
of
standards
and
accountability.
For
this
reason,
I'm
in
full
support
of
ab387.
H
I
think
it's
also
going
to
develop
a
professional
board
from
the
midwives
to
develop
standardized
criteria
for
education,
outline
a
path
to
licensure
and
provide
oversight,
disciplinary
action
when
needed.
I
think
it's
also
going
to
require
some
full
disclosure
to
make
the
public
clear
on
the
differences
between
the
different
midwives.
H
I
also
think
that
this
is
going
to
help
to
bridge
the
gap
between
ob,
gyns
and
midwives.
I
don't
think
there's
one
that's
better
than
the
other
necessarily
I
think
it's
a
matter
of
selection
of
patients.
I
think
that
that's
where
we're
falling
short
and
then
the
regulations,
I
think
it's
very
important
that
we're
collaborative
because,
in
times
of
need,
we
definitely
are
where
the
patients
are
presented.
C
G
I
am
speaking
on
behalf
of
myself.
I
am
also
the
current
president-elect
of
the
clark
county
medical
society.
I
am
a
nevada
licensed
and
board-certified
ob-gyn
physician
in
clark
county
and
I
have
lived
in
las
vegas
for
13
years.
I've
actively
provided
obstetric
care
to
the
women
of
nevada
for
those
13
years
prior
to
moving
to
nevada.
I
had
the
opportunity
to
learn
from
many
different
birth
providers
in
pennsylvania.
G
During
my
residency
training,
I
was
taught
primarily
by
obstetric
physicians,
but
I
was
also
fortunate
to
have
been
taught
by
certified
nurse
midwives
who
delivered
both
in
a
licensed
freestanding
birth
center
as
well
as
in
our
hospital.
I
am
a
better
obstetrician
because
of
the
lessons
I
learned
from
these
amazing
women.
G
I
learned
the
importance
of
provider,
education
and
collaboration
and
allowing
for
safe
birth
experiences.
The
pennsylvania
community
had
direct
entry
and
certified
professional
midwives
as
well,
and
these
birth
providers
all
had
physicians
that
they
could
consult
with
and
refer
patients
to
as
needed.
G
I
learned
that
the
best
birth
providers
were
not
those
who
were
cavalier
and
could
quote,
handle
everything,
but
instead
those
who
recognize
their
limitations
and
were
willing
to
ask
for
collaboration
and
assistance
when
this
was
warranted
from
these
amazing
midwives,
as
well
as
all
of
the
ob
gyn
physicians,
who
nurtured
and
taught
me.
During
my
four
years
in
pennsylvania,
I
became
the
obstetrician
I
am
today
when
I
moved
to
nevada.
I
learned
quickly
that
this
was
not
the
case
and
that
there
was
a
division
between
the
midwifery
community
and
the
community
of
ob
gyn.
G
This
is
something
that
I
believe
needs
to
be
repaired.
I
support
safe
birth
options
for
women
in
nevada,
and
I
am
in
support
of
licensure
and
educational
requirements
for
all
providers
of
birth
in
nevada,
including
physicians,
certified
nurse
midwives,
certified
professional
midwives
and
direct
entry
midwives.
The
safety
of
mothers
and
babies
in
nevada
is
of
the
utmost
importance
and
I
support
legislation
that
allows
birth
to
be
a
safer
experience.
A
Thank
you
for
your
testimony,
dr
mchale,
for
those
listening
over
the
internet.
We
have
time
for
one
more
caller
and
support,
and
then
we
will
move
into
opposition
if
you've
been
waiting
on
the
line.
Thank
you
so
much
for
your
patience
and
for
calling
in
to
provide
your
testimony,
but
unfortunately
we
will
not
have
time
to
hear
everyone's
testimony
who's
on
the
line.
So
I
would
encourage
you
to
please
have
your
remarks
sent
over
and
emailed
over
to
the
committee
manager.
A
C
G
G
A
Okay,
at
this
time,
we
are
going
to
move
into
testimony
and
opposition.
Before
we
go
to
those
on
the
telephone
line,
we
are
going
to
take
one
of
the
testifiers
who's
going
to
be
testifying
on
video.
I
believe
we
have
miss
ellison
junson
here
with
us
to
provide
testimony
and
opposition
is
ellis.
Ingenue,
butler
and
you're
ready.
I
Yes,
ready,
thank
you
so
much
good
evening
committee
on
commerce
and
labor
for
the
record.
My
name
is
alison,
juno
butler
and
I'm
a
nevada-based
certified
professional,
midwife
and
licensed
midwife
licensed
in
arizona
and
speaking
on
behalf
of
the
nevada
midwives
association
in
opposition
to
av-387,
as
it
was
posted
to
the
legislative
site.
Nma
consists
of
around
40
midwives
across
the
state,
including
certified
professional
midwives,
traditional
midwives
and
community
midwives,
who
are
deeply
committed
to
providing
the
highest
quality
midwifery
services
as
a
small
business
owner.
I
I
have
served
families
in
the
las
vegas
and
henderson
area,
and
also
from
tonopah
kingman
pahrump
to
moapa,
with
evidence-based
reproductive
health
care
services
of
approximately
30
midwives
serving
in
southern
nevada.
I
am
the
only
certified
professional
midwife
who
has
graduated
from
a
midwifery
education,
accreditation,
council,
meek,
approved
program,
and
thus
I
am
the
only
midwife
who
currently
meets
all
of
the
requirements
that
this
assembly
bill
wants
to
put
in
place
for
the
future.
I
I
Ab387
does
not
negate
or
alleviate
even
one
of
these
steep
barriers
for
nevada
midwives,
since
there
are
no
meek,
accredited
midwifery
schools
in
nevada,
not
all
individuals
are
able
to
afford
tuition
or
access
federal
student
aid
funding.
Only
five
of
the
11
meek
schools
accept
federal
student
funding.
I
Despite
my
passion
for
the
meek
pathway
to
midwifery
education,
I
recognize
that
these
challenges
may
be
even
greater
barriers
for
already
underrepresented
individuals
in
midwifery
and
higher
education,
including
black
indigenous
and
other
people
of
color.
Speaking
personally,
while
I
am
broadly
in
support
of
a
pathway
to
licensure
in
nevada
for
cpms
and
I'm
extremely
proud
of
my
meek,
education,
I
stand
in
opposition
to
this
assembly
bill
in
solidarity
with
my
nevada
midwives
association
colleagues
for
experienced
traditional
midwives
and
certified
professional
midwives,
who
went
through
the
narm
pep
process
to
become
national
board
certified
midwives.
I
I
am
someone
who
significantly
values
the
wonderful
relationships
that
I
have
with
physicians,
nurses,
hospitals
and
other
allied
health
professionals
in
southern
nevada.
I
can
also
speak
from
my
personal
experience
as
an
arizona
licensed
midwife
that,
despite
regulation,
licensure
and
parameters
meant
to
enhance
midwifery
integration
into
the
arizona
healthcare
system
that
licensure
has
not
in
any
way
integrated
midwives
with
physicians,
hospitals
and
allied
health
professionals.
I
Who've
refused
to
collaborate
with
licensed
midwives
such
as
myself,
despite
standardized
licensing
requirements,
shifting
to
statements
from
the
nevada
midwives
association
nma
opposes
ab387,
as
it
was
posted
on
the
legislative
site
while
nma
has
a
variety
of
concerns
about
av-387
as
it
relates
relates
to
commerce
and
labor.
Nma
is
primarily
concerned
that
av-387
would
cause
the
elimination
of
an
established
workforce
through
the
restraint
of
trade.
I
Additionally,
we
are
also
concerned
with
the
bill's
disregard
for
acceptability
and
equity
in
the
pathway
to
licensure
and
training,
along
with
ab387
requirements
that
extend
outside
of
licensed
cpms
to
other
direct
entry
midwives
to
meet
requirements
that
they
and
their
clients
are
not
in
support
of
restraint
of
trade
is
the
action
that
interferes
with
free
competition
in
the
market.
Av-387
restricts
the
trade
of
long-established
small
businesses
operating
in
the
state
of
nevada,
which
includes
historically
women-owned
businesses.
I
We
cannot
ignore
that
historically
and
currently,
midwifery
licensure
and
regulation
that
has
made
becoming
a
midwife,
extremely
difficult
or
prohibitive,
has
been
a
tool
of
oppression,
control,
racism
and
marginalization.
It
has
been
used
to
disenfranchise
already
historically
marginalized
communities
from
receiving
culturally
competent
and
representative
midwifery
care.
By
and
from
the
midwives
of
these
communities.
Our
national
and
state,
maternal,
parental
and
newborn
mortality
and
morbidity
numbers
show
the
outcomes
of
this
approach.
I
To
close,
we
cannot
support
a
bill
that
will
decrease
the
middle-free
labor
workforce
in
nevada,
negatively
impact
future
workforce
development,
detract
from
nevada's
historical
support
of
apprenticeship,
trades
negatively
impact,
primarily
women-owned.
Businesses
have
negative
financial
impacts
on
the
economy
and
cause
the
domino
effect
of
restricting
the
choices
of
women
and
birthing
people
in
nevada
midwives
make
a
difference
in
nevada's
parents,
80s
families
and
communities
are
counting
on
their
current
and
future
videos.
We
need
more
midwives,
not
fewer.
Thank
you
so
much
for
the
honor
of
speaking
with
you.
Thank.
A
C
H
I
So,
while
there
is
a
pathway
to
becoming
bridge
to
be
able
to
be
licensed
for
those
who
previously
don't
have
education,
what
that
tells
us
is
that
this
bill
is
doing
nothing
to
eliminate
the
barriers
that
have
prevented
these
individuals
from
going
through
a
meek,
education
pathway
in
the
future.
This
means
that
our
midwifery
workforce
is
not
going
to
continue
to
be
replenished.
I
We
need
more
midwives,
not
fewer,
and
if
the
vast
majority,
the
over
90
percent
of
midwives,
have
become
a
cpm
through
the
pep
process,
then
that
tells
us
that
there
are
issues
here
that
are
way
broader
than
av-387
allows
to
address,
and
so
we
cannot
ignore
the
future
impacts
of
that
on
this.
Through
this
bill,.
A
A
A
C
H
Thank
you.
My
name
is
justin
watkin
w-a-t-k-I-n-s.
Thank
you,
madam
chair
members
of
the
committee.
I
would
like
to
start
off
by
commending
the
bill
sponsor
and
the
presenters
today.
I
thought
it
was
a
very
organized
and
well
put
together
presentation,
one
of
the
best
I've
ever
seen,
and
I
want
to
support
the
bill,
but
it
falls
short
in
one
major
component,
and
that
is
the
stated
goal
of
accountability.
H
I've
had
the
unfortunate
circumstances
of
representing
clients
who
have
had
babies
die
as
a
result
of
midwife
negligence,
and
the
accountability
that
would
be
created
under
this
bill
currently
would
result
in
licensure
being
revoked
or
some
sort
of
administrative
effort,
but
that
does
not
fully
make
good
on
accountability,
because
there's
a
second
prong,
which
is
to
ensure
that
the
person
who
has
been
harmed
is
made
whole
here.
The
bill
would
provide
for
protection
under
the
medical
malpractice.
H
On
the
flip
side,
there
is
no
requirement
for
any
licensure
bond
or
insurance
limits,
and
while
we
do
not
have
anything
in
statute
that
requires
that
of
doctors
that
practice
in
hospitals,
the
hospitals
themselves
are
going
to
require
that
of
any
doctor
who
has
administration
rights
in
the
hospital.
So
insurance
coverage
is
not
a
problem
in
the
cases
that
I've
represented
my
client,
none
of
the
midwives
have
had
any
insurance
coverage
and
therefore
there
is
limited,
if
any
ability
to
make
my
client
whole,
financially
or
otherwise,
and
for
those
reasons
we
oppose
this
bill.
A
C
H
Good
evening
committee,
I
am
marlene
lockhart
representing
the
nevada
association
of
midwives,
and
I
am
calling
in
opposition
to
this
measure
reluctantly,
because
the
nevada
association
of
professional
midwives
has
a
bill
on
the
senate
side,
sb
271,
which
we
feel
more
comprehensively
addresses
the
goal
of
licensure
of
cpms
and
accomplishes
that
without
undue
burden
to
some
of
our
most
vulnerable
rural
and
minority
midwives.
Who
would
like
a
pass
to
a
licensure?
H
H
A
Thank
you
for
your
testimony.
I
I
do.
We
do
have
to
take
other
callers
in
opposition
and
we
are
on
a
time
limit,
but
I
did
have
a
question
for
you:
did
you
work
with
the
bill's
sponsor
throughout
the
process
and
did
the
build
sponsor
address
any
of
your
concerns
through
her
amendment.
H
Yes,
we
did
absolutely.
We
have
been
holding
stakeholder
meetings
all
summer
long
and
last
fall
and
assembly
woman
monroe
mourinho
participated
in
a
number
of
those
stakeholder
meetings.
We
have
sent
our
amendment
to
assemblyman
monroe
mourinho
and
we
had
a
discussion
as
late
as
today
about
the
amendment.
So
we
continue
to
be
hopeful
that,
on
the
narrow
issues
that
I
think
remain
to
be
resolved
that
they
can
be
resolved,
we
are
hopeful
that
they
be
resolved.
A
Well,
we
would
encourage
you
to
continue
working
with
the
sponsor,
and
I
would
I
would
like
to
remind
everyone
that
we
have
strict
committee
rules
that
require
all
amendments
and
exhibits
to
be
in
by
12
p.m.
The
day
before
the
meeting
meeting,
if
you
do
not
make
that
timeline,
your
material
has
the
possibility
of
not
making
it
on
to
nellis
on
time.
So
thank
you
ever
I'm
broadcasting
next
caller.
Please.
C
G
Hi,
my
name
is
danielle
gallant
and
thank
you
for
taking
the
time
to
listen
to
my
testimony.
I
know
it's
late
for
you
all.
I've
had
two
home
births,
one
in
california
and
one
in
las
vegas.
The
california
birth
was
overseen
by
a
meek,
midwife
and
the
las
vegas
home
birth
was
overseen
by
a
pep
midwife.
G
We
made
a
decision
really
based
on
economics.
I
handled
labor
better
than
most,
and
it
was
a
good
experience.
So
we
wanted
to
have
the
same
experience
in
nevada
with
our
second
child.
Both
firsts
were
amazing,
but
I
will
say
my
las
vegas
birth
was
emotionally
a
more
positive
and
more
welcoming
experience.
G
My
midwife,
sherry
hopkins
doula
and
my
husband
and
our
oldest
son
welcomed
our
little
one
into
the
world.
I
can't
explain
it
in
tangible
intangible
terms,
but
I
can
tell
you
that
it
just
felt
better,
I'm
all
for
licensing
from
midwifery
in
the
state
of
nevada,
because
this
bill
only
allows
one
type
of
education
from
an
organization
from
one
organization
make
us
that's
like
only
allowing
cpas
or
doctors
or
attorneys
from
harvard
that
does
not
open
up
options
for
women,
but
rather
drastically
limits.
It
mika
is
not
available
in
nevada
and
it's
expensive.
G
It
would
make
midwifery
in
nevada.
That
is
only
for
the
elite.
I'm
interested
in
thought
in
a
thoughtful
inclusive
bill
to
provide
licensing
that
will
give
nevadans
a
safe
home
birth,
but
also
options
and
accessibility
for
women
who
want
home
birth
or
cannot
afford
a
hospital
birth.
Allowing
other
educations
outside
of
nico
will
allow
for
more
qualified
midwives
in
nevada
and
will
allow
them
to
have
that
same
experience
that
I've
been
lucky
to
have.
Thank
you.
C
G
E-L-I-S-S-A-W-A-H-L,
so
I'm
just
a
freedom-loving
mom
who
has
a
lot
of
friends
in
our
midwives,
and
I
was
interested
in
a
home,
verse
myself
and
the
way
I
see
it.
You
are
dealing
with
philosophical
differences.
People
who
see
birth
as
either
medical
or
natural.
G
G
Your
fear
and
anger
that
you
may
have
seen
in
emails
you
may
hear
a
testimony
is-
is
really
about
the
lack
of
clarity
in
the
intent
that
there
will
still
be
non-cpm
midwives,
not
just
unlicensed
midwives,
but
non-cpm
midwives.
G
G
H
G
C
G
Hi,
it's
jessica,
lagore
l-a-g-o-r.
I
am
a
midwife
and
homebirthing
mother
in
las
vegas.
This
bill
removes
my
choice
of
birth
attendance
because
all
of
my
four
previous
perfectly
normal
births
would
be
considered
illegal
under
the
spill.
Ironically,
I
am
currently
over
43
weeks
pregnant,
which
makes
me
taboo
to
attend
under
this
bill,
but
I
still
believe
in
autonomy.
G
Currently,
personal
responsibility
is
still
a
thing
in
nevada,
but
if
you
allow
this
bill
to
pass,
we
will
not
be
able
to
say
that
anymore.
Additionally,
the
families
that
I
serve
do
not
want
to
sign
informed
consent
or
refusal
forms,
because
their
choices
do
not
come
with
fine
print.
This
bill
would
make
nevada
no
better
than
the
other
surrounding
tyrannical
states,
which
would
force
these
families
into
choices.
That
are
not
theirs.
G
G
Under
this
bill,
the
women
will
choose
to
have
their
babies
completely
alone
in
order
to
avoid
unnecessary
interventions
or
arbitrary
rules
that
they
don't
agree
with
and
that's
their
right.
This
bill
was
written
by
two
midwives.
However,
the
nevada
midwives
association
has
tracked
down
over
40
midwives,
who
are
opposed
to
this
bill.
As
an
industry,
we
do
not
approve
of
two
people
making
decisions
that
affect
everybody.
There
are
many
reasons
for
that
which
you
will
find
in
your
email
boxes.
Please
read
those.
G
You
will
also
notice
that
there
are
over
1100
votes
in
opposition
to
this
bill
and
the
polls
on
the
nevada
legislator
website,
because
the
families
do
not
consent
to
this
bill.
This
bill
removes
many
of
our
currently
valid
and
perfectly
acceptable
paths
to
midwifery,
including
placing
restrictions
on
the
time-honored
art
of
apprenticeship.
The
bill,
writers
and
bill
sponsors
have
consistently
been
closed
to
communication.
C
G
G
This
proposed
act
of
establishing
a
board
of
licensed
certified
professional
midwives
and
the
included
exemptions.
Provisions
and
requirements
is
burdensome,
overreaching
and
unnecessary.
I
believe
it
will
just
be
the
beginning
of
marginalizing
and
one
day
outlawing
my
current
freedom
to
home
birth
with
an
unlicensed
midwife
here
in
nevada.
G
I
know
that
all
guarantees,
accountability
or
better
outcomes
are
only
provisions
to
compensate
financially
when
something
goes
wrong
or
breaks.
Therefore,
I
have
never
held
the
false
belief
that
doctors
directed
birth
are
safer,
nor
even
that
midwife
assisted
birth
was
less
harmful
in
each
choice.
In
birthing
options,
I
made
the
best
informed
decision
I
could
for
my
family,
my
baby
and
myself
fully
understanding
the
best
outcomes
are
not
always
achieved,
despite
licensure
accredited
doctors
nor
word
of
mouth
unlicensed
midwives.
G
Finally,
my
fourth
home
birth
could
not
have
happened
in
the
manner
it
did
within
a
hospital
due
to
the
restrictive
protocols.
My
last
child
was
a
child
with
down
syndrome.
I
was
told
by
the
perinatal
expert
that
my
daughter
would
not
live
along
with
in
my
womb,
and
he
was
wrong.
She
lived
until
just
before
our
scheduled
cesarean
with
that
same
doctor.
G
C
G
G
I
am
concerned
that
ab387
would
cause
the
elimination
of
an
established
workforce
throughout
the
through
the
restraint
of
trade.
Ab387
may
have
disproportionately
negative
financial
impacts
on
rural
and
bypark
midwives,
their
students
and
communities.
Additionally,
I
am
also
concerned
that
the
bill's
utter
disregard
for
accessibility
and
equity
in
the
pathway
to
licensure
and
training.
G
Place
ab387
restricts
trade
of
long-established
small
businesses
operating
in
the
state
of
nevada.
It
also
includes
historically
women-owned
businesses
that
serve
rural
and
marginalized
communities.
It
would
also
restrict-
and
in
some
cases,
eliminate
the
midwifery
workforce
by
leaving
only
one
pathway
to
licensure
and
eliminating
the
ability
of
cpm
students
to
find
preceptors
in
their
own
communities,
causing
students
to
incur
deep
financial
losses
in
pursuit
of
their
training.
The
lack
of
diversity,
accessibility
and
equity
in
midwifery
education
has
long
been
documented,
and
this
bill
perpetuates
historical
biases
and
disenfranchisement.
G
G
That
means
that
it's
a
greater
burden
for
us
to
try
to
extend
our
training
and
get
what
we
need
from
also
historically
marginalizing
and
historically
racist
educational
systems,
so
to
say
that
there
are
no
barriers
or
that
the
barriers
are
minimal
means
that
they
have
not
walked
a
day
in
my
skin.
They
have
not
stepped
through
the
hoops
that
I've
had
to
step
through
to
get
through
the
training
that
I've
needed
to
get
being
closed
out
from
midwives.
Who
would
no
longer
take
me.
A
C
G
My
name
is
rebecca
wells
w-e-l-l-s
and
I
am
an
about
a
midwife
and
I
oppose
this
bill.
I
was
honored
to
be
given
the
opportunity
to
learn
the
trade
of
midwifery
to
the
age-old
tradition
of
apprenticeship
of
two
of
nevada's
most
experienced
midwives.
They
began
helping
women
to
live
their
babies
outside
of
the
medical
model
and
in
their
own
homes.
In
the
late
1970s
and
early
1980s
between
the
two
of
them
they
represent
approximately
5
000
deliveries
over
more
than
four
decades.
G
One
of
them
is
still
helping
women
have
their
babies
and
also
opposes
this
bill.
During
my
apprenticeship,
they
conscientiously
passed
their
knowledge
and
experience
to
me
as
we
attended
birch
together
over
the
course
of
approximately
three
years.
This
bill
seeks
to
eliminate
this
pathway
to
midwifery
and
instead
replace
it
with
only
one
exclusive
past.
There
is
only
one
organization
with
which
to
obtain
a
cpm
certificate
and
requiring
one
in
nevada
to
practice.
Midwifery
will
severely
limit
those
who
can
assist
other
women
in
out
of
hospital
delivery.
G
There
will
always
be
women
who
wish
to
deliver
their
babies
outside
of
the
medical
model.
If
the
number
of
midwives
are
limited,
then
those
women
are
left
with
limited
choices
most
if
not
all
of
them
will
still
deliver
their
babies
in
their
home,
but
they
will
do
so
without
any
type
of
trained
attendant.
We
know
this
because
we
have
been
watching
the
results
in
other
states
who
license
one
type
of
midwives
while
criminalizing
other
midwives.
G
If
those
women
have
the
ability
to
travel
to
nevada
for
their
birth,
they
often
do
if
they
don't,
they
will
go
it
alone.
If
this
bill
passes
as
written,
it
will
severely
limit
trade
in
nevada.
Please
note
that
this
bill
was
written
and
is
supported
by
only
two
of
nevada
midwives.
The
remainder
approximately
40,
are
opposed
to
this
bill,
but
many
of
them
are
in
favor
of
sb271,
which
is
another
bill
for
licensing
midwives.
Proponents
of
this
bill
claim
that
this
will
only
affect
those
ppm
to
wish
to
be
licensed
without
cotton
leaf
falls.
G
They
have
written
into
the
bill
a
requirement
that
midwives,
who
wish
to
remain
about
a
license,
have
to
have
their
client
sign
a
form
provided
by
their
bill,
stating
that
they're
or
I'm
sorry
they're
bored
stating
that
they
are
unlicensed.
Our
clients
already
know
this.
This
is
what
they
are
choosing.
We
do
not
wish
to
be
governed
by
their
licensure
bill,
but
rather
to
be
left
alone
to
continue
doing
what
women
have
been
doing
for
each
other
since
the
beginning
of
time.
Thank
you.
C
G
I
am
las
vegas
resident.
I
have
four
children
who
are
all
born
in
nevada
and
all
home
birth.
I
never
intended
to
be
a
home
birthing
mother.
With
my
first
birth,
I
was
going
to
have
a
water
birth
at
summerlin
hospital.
With
dr
harder.
The
day
I
was
in
labor
upon
arriving
at
the
hospital.
I
was
informed
that
my
doctor,
dr
harder,
was
not
on
staff
and
that
the
doctor
on
staff
was
not
comfortable
with
water
birth
and
that
it
would
no
longer
be
a
delivery
option.
For
me,
I
was
then
put
into
a
bed.
G
I
went
from
being
home
where
I
was
able
to
move
my
body
freely
to
being
stuck
in
a
bed.
The
fetal
monitor
kept
slipping
down.
My
stomach,
causing
the
baby's
heart
rate
to
go
missing,
which
caused
my
anxiety
to
spike.
When
the
doctor
came
in,
they
told
me
they
needed
an
ultrasound
to
see
the
baby's
positioning
upon
which
we
discovered
he
was
breached
and
said
that
I
needed
to
have
an
emergency
c-section.
G
I
asked
the
doctor
to
give
me
a
moment,
so
I
could
process
and
talk
it
out.
She
said
what
is
there
even
to
think
about?
If
you
don't
have
a
c-section,
you
will
kill
your
baby.
I
researched
first,
and
I
knew
that
I
had
some
options
to
try
to
get
the
baby
to
move.
I
could
walk
around
or
do
spinning
baby
techniques.
They
told
me
no,
I
had
to
stay
in
the
bed.
When
my
duel
arrived,
I
asked
if
she
knew
any
other
options
I
so
desperately
wanted
to
have
a
natural
birth.
G
I
knew
that
having
a
c-section
was
a
difficult
delivery
to
heal
from,
and
I
wanted
to
prevent
myself
from
having
one.
I
also
knew
women
had
delivered
breach
babies.
Naturally
she
told
me
my
only
option
was
to
hire
a
midwife.
She
quickly
made
phone
calls
and
found
one.
I
did
have
the
natural
birth
I
wanted.
I
just
had
to
do
it
at
home
and
I
didn't
kill
my
baby.
The
doctor
was
wrong.
My
home
birth
changed
my
life
and
empowered
me
as
a
woman,
mother
and
a
person.
I
urge
you
to
vote
against
this
bill.
G
A
Thank
you
so
much
for
your
call
for
those
listening
over
the
internet.
We
will
take
one
more
in
opposition
and
then
transition
over
to
testimony
and
neutral
broadcasting.
If
we
could
go
to
our
last
caller
in
opposition
and
those
who
are
in
opposition,
I
would
again
encourage
you
if
you
are
on
the
line
and
did
not
get
the
opportunity
to
testify.
Please
send
in
your
written
remarks
to
our
committee
manager
and
she
will
include
them
in
the
record
again.
You
can
email
the
assembly
at.
C
G
Thank
you,
I'm
speaking
today
on
behalf
of
nevada
friends
of
midwives,
since
2002
nfom
has
worked
to
protect
parental
rights
as
they
pertain
to
childbirth.
We
have
hundreds
of
members
and
we
are
strongly
opposed
to
this
bill.
I
would
like
to
share
my
personal
story.
When
I
was
pregnant
with
my
third
baby,
I
lived
in
arizona.
I
had
done
a
lot
of
research
and
I
knew
what
I
wanted
for
my
birth.
G
I
was
under
the
care
of
a
licensed
cnn
using
medicaid.
Imagine
my
disgust
and
anger
when
I
learned
that
the
state
board
prohibited
her
from
attending
me
at
a
birthing
center.
Simply
because
I
had
had
a
previous
cesarean.
I
looked
for
other
options,
but
home
birth
midwives
in
arizona
are
also
not
allowed
to
attend
v
backs.
This
prohibition
is
not
based
on
evidence
and
I
knew
it
so.
My
choices
were
to
give
birth
in
a
hospital
or
give
birth
at
home
alone.
G
Both
were
out
of
the
question
for
me,
so
I
moved
back
to
nevada
to
give
birth.
Yes,
that's
correct.
I
moved
from
another
state
to
have
the
birth
I
wanted.
I
gave
up
my
medicaid
coverage.
Despite
being
an
extremely
poor
person-
and
I
hired
an
unlicensed
midwife
after
very
carefully
informing
myself
in
regards
to
her
experience
and
training
in
weekly
support
groups,
we've
heard
hundreds
of
stories
similar
to
mine.
The
authors
say
that
parents
will
still
be
able
to
hire
whomever
they
like,
but
this
bill
is
missing
important
intention
language.
G
If
the
intent
is
to
license
cpms,
then
all
other
midwives
must
be
completely
exempt.
They're
not
carrying
drugs,
they're
not
practicing
medicine,
and
they
do
not
wish
to
build
medicaid.
They
don't
belong
in
this
bill.
Section
152
requires
non-licensed
midwives,
provide
a
so-called
informed
consent
form.
This
requirement
implies
incorrectly
that
non-licensed
midwives
need
permission
of
the
state,
though
all
midwives
in
nevada
have
always
been
legal
and
attempts
to
place
them
under
a
board
have
been
rejected
again
and
again,
notably
in
1982.
G
The
attorney
general
refused
to
place
midwives
under
the
board
of
health,
stating
that
it
would
restrict
trade
and
be
paramount
to
a
licensure
scheme.
This
language
is
denigrating
and
marginalizing.
It
is
meant
to
manipulate
public
opinion
against
some
midwives.
Some
of
these
midwives
have
been
practicing
since
the
1980s
and
have
delivered
thousands
of
babies.
It
also
implies
that
the
parent
is
culpable
in
some
way
who
may
have
to
answer
to
someone
for
their
decisions.
G
The
agreements
that
parents
and
midwives
make
are
intensely
personal
and
private
and
such
a
form
and
an
invasion
of
privacy.
The
parents
of
nevada
have
spoken
loud
and
clear
with
your
opinion
poll.
They
are
saying
my
body,
my
birth,
my
choice,
nevada,
friends
and
midwives
hopes
to
see
this
bill
dropped
completely.
Thank
you
for
your
time.
A
Thank
you,
miss
alvarez
and
again,
thank
you
for
everyone
who
called
in
in
opposition
at
this
time.
We
are
going
to
move
to
testimony
in
the
neutral
position.
I
do
not
have
anyone
signed
up
to
testify
on
video,
so
we
will
move
directly
to
the
phone
lines.
I
would
like
to
note
for
those
listening
wishing
to
testify
in
a
neutral
position
that
testifying
in
the
neutral
position
means
that
you
do
not
take
a
position
on
the
bill.
You
are
not
in
support
of
it
or
in
opposition
of
it.
A
You
are
in
a
neutral
position,
meaning
you
do
not
have
a
position
on
it.
If
your
testimony
is
indicative
of
leaning
in
support
or
opposition,
I
will
ask
you
to
redirect
your
comments
or
terminate
them
and
move
on
to
the
next
caller
with
that
broadcasting.
If
we
could
check
the
telephone
line
for
anyone
wishing
to
testify
in
the
neutral
position,.
C
G
G
Sorry,
I
really
can't
read
like
finance
numbers,
so
it's
basically
over
four
hundred
and
nine
thousand
dollars,
and
so
the
medical
savings
on
that
was
approximately
four
hundred
and
sixty
one
thousand
dollars,
eight
hundred
and
thirty
dollars-
and
there
are
some
system
costs
involved
at
about
fifty
two
thousand
dollars,
but
still
overall,
we
have
a
cost
savings
of
over
four
hundred
and
nine
thousand
dollars.
So
when
you
look
at
the
fiscal
note
for
the
division
of
health
care,
financing
and
policy,
you'll
see
negative
fiscal
numbers
there,
which
means
that
it's
a
cost
saving.
Thank
you.
A
A
A
C
G
Good
evening,
madam
chair
and
assembly
members
of
the
board
for
the
record,
my
name
is
romina
paulucci
and
I
am
a
parterra
midwife
in
las
vegas.
I
apprenticed
here
under
norm
certified
midwest
known
as
cpm,
one
of
which
was
norm
or
meat
certified,
and
for
lifestyle
and
philosophical
reasons.
I
did
not
sit
for
an
exam
and
certify
as
a
cpm.
G
A
A
D
I
think
what
we've
heard
are
a
lot
of
passionate
comments
coming
from
the
callers
and
in
response
to
the
opposition
there,
a
number
of
the
comments
were
made
about
the
bill
as
it
was
introduced
and,
as
I
said
in
our
opening
statement,
we
too
were
in
opposition
some
of
the
items
in
the
bill
as
introduced
and
therefore
those
items
were
discussed
and
addressed
in
the
amendment.
D
D
That
is
a
bill
that
is
being
carried
by
senator
hammond
in
the
senate.
We,
as
a
group
of
supporters
of
this
bill,
had
numerous
meetings
with
the
stakeholders
of
that
bill.
However,
I
did
go
out
of
my
way
earlier
today
and
have
communications
with
senator
hammond
about
his
bill,
wondering
where
was
at
in
the
senate.
I
am
not
in
that
body,
so
I'm
not
sure
how
things
are
processing
through
their
house.
D
His
comment
was
that
his
bill
has
a
number
of
problems
and
therefore
he
doesn't
know
if
he'll
be
able
to
fix
it
in
time
for
this
legislative
session.
So
I
don't
know
where
that
bill
is
going,
but
I
would
like
to
thank
an
organization
named
make
it
work.
It's
an
organization
that
works
with
women's
health
care
issues
and
especially
in
our
communities
of
color,
which
you
heard
a
number
of
times
from
some
of
the
opposition,
make
it
work
offered
to
hold
community
stakeholder
meetings.
D
For
me
to
get
information
that
I
was
not
able
to
get
because
we're
in
legislative
session,
and
my
schedule
was
a
little
tight
and
with
those
meetings,
I'm
open
the
conversation
to
people
that
we
had
not
had
a
conversation
with
leading
into
this
legislative
session,
but
also
continuing
the
conversation
that
we
had
had
with
a
number
of
midwives
to
address
some
of
the
issues
that
last
meeting
was
actually
saturday
afternoon.
Almost
a
four-hour
meeting
with
miss
jolene
simpson,
who
did
call
in
an
opposition,
gave
a
number
of
suggestions
that
are
included
in
the
amendment.
D
While
I
admit
I
did
not
have
a
conversation
with
everyone
that
was
in
opposition,
some
of
the
people
were
very
threatening
in
some
of
their
emails
and
facebook
posts.
So
I
felt
that
I
it
was
not
in
the
best
interest
of
my
time
or
in
the
best
interest
of
the
state
to
carry
on
a
conversation
that
was
not
going
to
be
fruitful
to
come
to
a
mutual
conclusion.
D
I
want
to
thank
you.
There
was
a
lot
of
information
that
was
shared
today.
You
probably
know
more
about
midwives
than
you
ever
thought.
You
would
want
to
know,
but
as
a
mother
and
as
a
grandmother
who
my
daughter
had
options,
I
want
moms
families
in
the
state
of
nevada
to
have
options,
and,
yes,
women
have
the
last
voice
over
what
happens
to
their
bodies
the
very
last
voice.
No
one
else
can
say
what
happens
to
a
woman's
body
other
than
that
woman.
A
Thank
you,
assemblywoman
monroe
moreno
with
that
committee
members.
I
will
close
the
hearing
on
assembly
bill
387
our
last
and
an
agenda
item
for
this
evening
is
going
to
be
public
comment
and
while
we
are
giving
those
listening
over
the
internet
time
to
call
in,
I
am
going
to
read
our
public
comment
housekeeping
room,
I'd
like
to
remind
everyone
that
the
period
for
public
comment
is
an
opportunity
to
discuss
general
matters
that
fall
within
the
purview
of
this
committee.
A
The
public
has
already
been
given
time
to
support
or
oppose
specific
legislation
we
open
and
close
hearing
on
bills
so
that
we
can
establish
a
public
record
of
the
testimony
on
a
bill.
Therefore,
public
comment
is
not
intended
to
be
a
continuation
of
a
bill
hearing.
I
would
like
to
remind
everyone
that
we
limit
public
comment
to
two
minutes
and
again,
please
address
your
remark
to
issues
that
fall
within
the
commerce
and
labor
committee.
A
If
you
direct
your
remarks
to
issues
over
which
we
have
no
jurisdiction,
I
will
ask
you
to
redirect
your
remarks
or
terminate
them.
Please
be
respectful
of
committee
members
and
other
witnesses.
Do
not
comment
on
testimony.
Provided
by
other
speakers
and
do
not
make
personal
attacks,
you
may
always
submit
written
remarks
for
inclusion
in
the
meeting
record
with
that
broadcasting.
Is
there
anyone
on
the
telephone
line
wishing
to
give
public
comment.
C
G
A
C
C
G
A
C
G
Hi
for
the
record,
my
name
is
camilla
santiago,
c-a-m-I-l-a
s-a-n-t-I-a-g-o,
I'd
like
to
testify,
because
I'm
originally
from
brazil,
but
currently
I'm
us
citizen
in
nevada
at
heart.
Since
I
arrived
here
to
stay
in
2007.,
both
of
my
children
were
born
here
and
at
home
with
the
assistance
of
a
cpm.
And
if
you
don't
know,
brazil
is
known
by
the
country
of
c-sections.
G
G
Make
accredited
institutions
I
would
partic
would
particularly
require
me
for
prerequisite
prerequisites
such
as
esl,
english,
101,
math,
101,
plus
the
midway
for
pre-active
prerequisites
and
making
this
process
absolutely
more
expensive
and
more
time
consuming
more
inaccessible
in
comparison
to
someone
that
was
born
here,
attended
high
school
or
college
in
the
u.s.
In
a
brief
addition,
this
bill
requires
taking
an
antibiotic
racism.
Training
norm
already
requires
that
type
of
training
from
phase
one
of
the
pep
process
and
the
bridge
requires
use
from
accredited
sources
like
meek,
acog,
acnm,
state
health,
department's
nursing,
perennial
associations.
A
C
C
G
F,
l
t
t-
and
I
wasn't
fast
enough
to
get
into
a
different
queue,
but
I
would
like
to
just
encourage
the
committee
members
of
this
committee
to
do.
Please
go
look
at
the
opinion
poll
that
is
on
the
nevada
legislature
on
the
nellis
regarding
this
bill,
because
the
parents
of
nevada
have
spoken.
Thank
you.
This
ends
my
comment.
A
C
G
My
name
is
mary
gilbert
m-a-r-y-g-I-l-b-e-r-t
for
the
record,
and
I
just
want
to
say
that
medicaid
being
able
to
cover
this
bill
or
to
cover
midwives
would
make
a
radical
difference
in
our
community.
G
When
I
gave
birth
to
my
son
twelve
years
ago,
I
paid
fifteen
thousand
dollars
out
of
pocket
because
I
wasn't
insured.
When
I
paid
for
my
midwife,
it
cost
less
than
five
thousand
dollars.
C
A
Okay,
thank
you
so
much
and
committee
members.
Thank
you
so
much.
I
know
it's
been
a
long
day
for
us
with
two
cummerson
labor
agendas.
I
appreciate
the
attention
that
everyone
has
so
diligently
gave
to
this
bill
hearing
and
to
those
who
called
in
to
testify
and
support
opposition,
neutral
and
public
comment.
A
We
will
see
you
on
wednesday
again,
please
be
on
the
lookout
for
the
time
on
the
agenda.
We
will
be
starting
earlier
than
our
normal
scheduled
start
time
at
1
pm,
and
thank
you
again
for
being
here
with
that.
We
are
adjourned.
Thank
you.